Chapter 1 
The responsibilities of being a physiotherapist
Ceri Sedgley
INTRODUCTION
This chapter provides an insight into what it means to be
a physiotherapist and a member of the physiotherapy pro­
fession in the UK.
The chapter explores the development of the profession
and how physiotherapy acquired the privileges and re­­
sponsibilities of autonomous practice, and explores the
consequences of that for contemporary professional
practice.
Finally, the chapter considers how the changing shape
of health services in the UK and society’s increasing expec­
tations of health professionals to deliver safe, high-quality
health services within finite resources and which patients
can trust are shaping physiotherapy practice. The ways in
which physiotherapists can demonstrate the quality of
both, practice and service delivery, through clinical govern­
ance, play vital role and this is also discussed.
The term patient has been used throughout this chapter
to describe the individual to whom physiotherapy is being
delivered. It is recognised that at times the term service
user is more acceptable for some groups to whom physio­
therapists provide intervention, e.g. in illness prevention.
The term physiotherapist has been used throughout the
chapter, but it is recognised that the chapter will also be
of relevance to students and support workers, and others
involved in delivering physiotherapy services.
BACKGROUND TO THE CHAPTER
Tidy’s Physiotherapy has been a key text for physiotherapists
over the years. Earlier editions have provided prescriptive
descriptions of what physiotherapists should do in
particular situations or for specific conditions. This
prescriptive approach has become less relevant to the
delivery of contemporary healthcare and recent editions
of this chapter have demanded critical thinking from the
reader. This reflects the development of the profession and
the diversity of roles and settings physiotherapists deliver
services within, both alone and within teams, providing
healthcare for a diverse range of conditions. This change
has been reflected in the education of physiotherapists
focussing on developing analytical and clinical reasoning
skills individualised to the patient. Recent editions of this
chapter have, therefore, demanded critical thinking from
the reader.
No two patients, clinical situations or professional
roles are the same; each requires the physiotherapist to
use their skills and knowledge to determine the most
appropriate action. In a clinical situation, physiotherapists
must use their skills and knowledge to carry out a full
and accurate assessment and, using clinical reasoning
skills and considering the individual patient, offer ap­­
propriate options for management. Throughout the
decision-making process the patient should be educated
and informed of the options available, and be given the
opportunity to participate fully in their management. This
includes consideration of the indication for managing
the patient in physiotherapy, discharging them or referring
them on. The responsibility for this decision-making
process lies with the physiotherapist and the physiothera­
pist is accountable for this decision, hence the dichotomy
of autonomy as both a privilege, i.e. the ability to act
independently, and a responsibility, i.e. having accounta­
bility for the decisions made.
Accepting the responsibility requires maturity and
an understanding of the implications of this responsibil­
ity. The individual physiotherapist must also understand
the concept of scope of practice, competence, and the
individual nature of scope (CSP 2008). An individual’s
scope will change throughout their career and competence
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 Tidy’s physiotherapy
must be maintained through career-long learning, through
self-evaluation of both the physiotherapist’s learning
needs and the service required, for example, maintaining
currency with the most effective interventions. This com­
mitment will maintain the trust of the patient and the
public in both the individual and the profession.
HISTORY OF THE PHYSIOTHERAPY
PROFESSION
This section provides an overview of the development of
the physiotherapy profession with a particular focus on
the development of autonomy and regulation of physio­
therapy. An overview of the early days of the profession
can be found in the book In Good Hands (Barclay 1994).
Further references may be found in The History of the
Phys­iotherapy Profession (CSP 2010), which provides an
insight into the development of autonomy and, sub­
sequently, scope of practice.
The Chartered Society of Physiotherapy (CSP) was
founded in the UK in 1894, under the name of the Society
of Trained Masseuses. It was established as a means of regu­
lating the practice of ‘medical rubbers’. For many years,
doctors governed the profession and one of the first rules
of professional conduct stated ‘no massage to be under­
taken except under medical direction’ (Barclay 1994). The
Society used the opportunities created by developments in
medicine and technology, and the demands of war to
extend its manual therapy skills, and to add exercise and
movement, electrophysical modalities and other physical
approaches to its repertoire during the early years of
the twentieth century (Barclay 1994). This scope of prac­
tice, which was legitimised by a Royal Charter in 1920,
remains the hallmark of contemporary physiotherapy
practice (CSP 2008).
Physiotherapy continued to evolve and consolidate its
position during the 1930s and 1940s. This was achieved
through ongoing patronage of the medical profession and
recognition of physiotherapy’s contribution to society’s
health and well-being. The development of the Welfare
State during the 1940s created opportunities for physio­
therapy to apply and develop its practice across a growing
range of medical specialisms (Barclay 1994). Physio­
therapy training moved into hospital-based schools during
1948, which effectively meant that newly qualified physio­
therapists were prepared for practice in National Health
Service (NHS) hospitals. Over time, the NHS became the
primary employer of physiotherapists.
Physiotherapy’s quest for self-regulation during the
1950s was quashed by the medics who had effectively
established control of its practice through sustained
involvement in the CSP’s governance structures and
ongoing patronage. Following intense lobbying by physio­
therapy and other healthcare professions, the Council
2
of Professions Supplementary to Medicine (CPSM) opened
a physiotherapy register in 1962 which represented a shift
in the power of medicine over physiotherapy. Despite the
introduction of state regulation, doctors continued to
assert full responsibility for patients in their charge,
arguing that ‘professional and technical staff have no right
to challenge his views; only he is equipped to decide how
best to get the patients fit again’ (Barclay 1994).
It took more than 80 years for the physiotherapy profes­
sion to progress from the paternalism of doctors, on
whom physiotherapists were dependent for referrals. The
first breakthrough came in the early 1970s, when a report
by the Remedial Professions Committee, chaired by Pro­
fessor Sir Ronald Tunbridge, included a statement that,
while the doctor should retain responsibility for prescrib­
ing treatment, more scope in application and duration
should be given to therapists. The McMillan report (DHSS
1973) went further, by recommending that therapists
should be allowed to decide the nature and duration of
treatment, although doctors would remain responsible for
the patient’s welfare. This recognised that doctors who
referred patients would not be skilled in the detailed appli­
cation of particular techniques, and that the therapist
would therefore be able to operate more effectively if given
greater responsibility and freedom.
Eventually, in the 1970s, a ‘Health Circular, Relationship
between the Medical and Remedial Professions’ was issued
(DHSS 1977). This acknowledged the therapist’s compe­
tence and responsibility for deciding the nature of the
treatment to be given. It recognised the ability of the phys­
iotherapist to determine the most appropriate interven­
tion for a patient, based on knowledge over and above that
which it would be reasonable to expect a doctor to possess.
It also recognised the close relationship between therapist
and patient, and the importance of the therapist inter­
preting and adjusting treatment according to immediate
patient responses, thus securing professional autonomy.
This autonomy brought responsibilities and the ongoing
need for physiotherapists to demonstrate competence in
decision-making, building up the trust of doctors and
those paying for physiotherapy services. This was reflected
in the inclusion of skills of assessment and analysis as a
key component of the qualifying curriculum introduced
in 1974.
Two years after gaining professional autonomy in 1977,
and supported by the shifts in physiotherapy education
towards polytechnics, the CSP opened the debate on
all-graduate entry – an identity traditionally associated
with professions (Tidswell 1991). All-graduate entry was
finally achieved in 1994 following considerable debate
about how degree status would benefit patients and
ensure the ongoing development of physiotherapy prac­
tice (Tidswell 2009).
In 1996 delegation of activities to healthcare prac­
titioners, including some medical tasks, was facilitated
by the document ‘Central Consultants and Specialists
 The responsibilities of being a physiotherapist
Committee: Towards tomorrow – The future role of the
consultant’ (Marriott 1996). The content of this report,
together with the political drivers to contain healthcare
service costs and maximise productivity, created new
opportunities for physiotherapists to develop new skill-
sets to undertake tasks that were previously the domain
of medicine. These ‘extended’ roles were typically found
in musculoskeletal medicine: physiotherapists working
alongside doctors triaging patients on the waiting list or
providing ongoing medical management of people with
long-term conditions. Over time, these roles shifted into
other medical specialisms, such as neurology, respiratory
care and women’s health – evidence of the clinical- and
cost-effectiveness of this model of practice.
Towards the end of the 1990s, concerns about the
quality of patient care, professional power and the need
to contain the spiralling medico-legal costs, led to an over­
haul of the regulatory frameworks in healthcare. Clinical
governance was introduced as a system of quality control
in 1997. Discussions about the need to review the regula­
tion of professional groups like physiotherapy who worked
alongside medicine, led to a change in terminology in
1999, from ‘professions supplementary to medicine’ to
‘health professions’. Legal protection of the title ‘physio­
therapy’ and ‘physical therapist’ followed under the Health
Professions Order (DH 2002, HCPC 2001) – an outcome
that the Chartered Society had been seeking for over 30
years. Alongside protection of title came a whole raft of
changes designed to strengthen and modernise the regula­
tion of healthcare professions, including physiotherapy.
The CPSM was replaced by the Health Professions Council
(HPC) in 2002 and subsequently renamed the Health and
Care Professions Council (HCPC) in 2012. One of the
most significant changes for registrants was the introduc­
tion of a process to audit their ongoing competence
to practise and requiring engagement with continuing
professional development (CPD) (HCPC 2011).
Once the physiotherapy profession had acquired all-
graduate entry, physiotherapy continued its pursuit of pro­
fessional traits by shifting the debate from examination of
skills and techniques to attempting to identify the under­
pinning knowledge that makes it unique (Roberts 2001).
This change is reflected in both the Physiotherapy Frame­
work (CSP 2011c) and the Learning and Development
Principles (CSP 2011b).
In 2007 the CSP Council agreed a fresh interpretation
of the Royal Charter:
… the scope of practice is defined as any activity
undertaken by an individual physiotherapist that
may be situated within the four pillars of
physiotherapy practice where the individual is
educated, trained and competent to perform that
activity. Such activities should be linked to
existing or emerging occupational and/or practice
Chapter 1
frameworks acknowledged by the profession, and
be supported by a body of evidence…
(CSP 2008)
Most recently, the CSP Council agreed to a new Code
of Professional Values and Behaviour (CSP 2011a) that
brings to the fore CSP member responsibilities relating to
scope of practice, including the responsibility to consult
with the CSP if a member is aware that a new area of
practice challenges the boundaries of recognised scope of
practice.
Physiotherapy has used the opportunities created by
changes in society, developments in science and technol­
ogy, and transformations in the design and delivery
of education and healthcare, to evolve into what the pro­
fession is today.
RESPONSIBILITIES OF BEING  
A PROFESSIONAL
Since its inception in 1894, physiotherapy practice has
been governed by a set of legal, regulatory and ethical
frameworks and these are explored here. As described
earlier, physiotherapists, as part of a profession, have
certain rights or privileges together with a responsibility
to themselves, the patient, the profession and the organi­
sation within which they undertake their professional
role. These responsibilities sit within legal, organisational
and regulatory frameworks.
Characteristics of a profession
There are various theories on how to describe a profession
in the literature. One way reflects work undertaken during
the 1950s and 1960s which explored professions by
identifying common traits and considering the qualities
that distinguished a profession from an occupational
group (Koehn 1994; Richardson 1999). A profession is
described as:
• licensed by the state;
• a professional organisation which has developed and
maintains a code of conduct or standards of practice
based on acknowledged ethical principles;
• able to discipline members who contravene the
code/standards;
• having exclusive knowledge and a technical base
which is protected by the law;
• autonomous in its members’ work;
• having members undertaking professional activity
which requires them to have responsibilities or
duties to those who need assistance;
• having responsibilities which are not incumbent on
others.
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 Tidy’s physiotherapy
By creating evidence of these traits, professions have
been able to justify their ability to exercise power within
society. As illustrated above, physiotherapy has sought
to acquire the traits associated with a profession over
time. From its inception in 1894 as an occupational
group trained and examined in medical massage, physio­
therapy has established a distinctive knowledge and skill-
base that was first recognised by a charter in 1920, and
more recently by achieving all-graduate entry – which also
serves to ensure the maintenance and development of its
unique knowledge and skills-base. The responsibilities of
professional practice are expressed and regulated through
standards which are regulated by the state.
Professionalism defines what is expected of a profes­
sional. Becoming an autonomous professional requires an
acceptance, often implied, of certain responsibilities, in
return for certain privileges. These responsibilities require
behaviours and attitudes of individuals in whom profes­
sional trust is placed. Professionalism is widely under­
stood to require these attributes (Medical Professionalism
Project 2005 (cited in CSP 2005b); CSP 2011a):
• a motivation to deliver a service to others;
• adherence to a moral and ethical code of practice;
• striving for excellence;
• maintaining an awareness of limitations and scope
of practice, and a commitment to empowering others
(rather than seeking to protect professional
knowledge and skills).
However, defining and providing evidence of profes­
sionalism is often more complex. A recent research report
by the HCPC (2011) considered the concept of profession­
alism as many fitness to practise cases referred to regula­
tors include professionalism. The report summarised that:
… professionalism has a basis in individual
characteristics and values, but is also largely
defined by context. Its definition varies with
a number of factors, including organisational
support, the workplace, the expectations
of others, and the specifics of each service
user/patient encounter. Regulations provide basic
guidance and signposting on what is appropriate
and what is unacceptable, but act as a baseline
for behaviour, more than a specification…
A profession that fulfils these expectations establishes
and maintains credibility with the public and demon­
strates its capacity to carry the privileges of professional
practice – autonomy and self-regulation. In turn, fulfil­
ment of these expectations demonstrates a profession’s
ability to fulfil the parallel responsibilities of professional
practice – accountability, transparency and openness.
A key element of physiotherapy students’ preparation
for practice on qualification is their being supported in
developing their understanding of, and engagement with,
the responsibilities and privileges that professionalism
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encapsulates. The concept of professionalism also relates
strongly to the role of physiotherapy support workers.
Possessing knowledge and skills  
not shared by others
Any profession possesses a range of specific knowledge and
skills that are either unique or more significantly devel­
oped than in other professions. For physiotherapy, the
roots of the profession can be found in massage. Physio­
therapists continue to use massage therapeutically, as well
as employing a wide range of other manual techniques,
such as manipulation and reflex therapy. Therapeutic hand­
ling underpins many aspects of rehabilitation, requiring
the touching of patients to facilitate movement, and the
significance of therapeutic touching of patients still sets
physiotherapy aside from other professions.
The World Congress for Physical Therapy (WCPT)
states that:
Physical therapy provides services to individuals
and populations to develop, maintain and
restore maximum movement and functional
ability throughout the lifespan. This includes
providing services in circumstances where
movement and function are threatened by
ageing, injury, diseases, disorders, conditions or
environmental factors. Functional movement is
central to what it means to be healthy…
(WCPT 2011)
Cott et al. (1995) proposed an overarching framework
for the profession: the movement continuum theory of
physical therapy, arguing that the way in which physio­
therapists conceptualise movement is what differentiates
the profession from others. They suggest that physiothera­
pists conceive movement on a continuum from a micro-
(molecular, cellular) to a macro- (the person in their
environment or in society) level. The authors argue that
the theory is a unique approach to movement rehabilita­
tion because it incorporates knowledge of pathology
with a holistic view of movement, which includes the
influence of physical, social and psychological factors into
an assessment of a person’s maximum achievable move­
ment potential. They argue that the role of physiotherapy
is to minimise the difference between a person’s current
movement capability and his/her preferred movement
capability.
In the UK, one approach to conceptualising physiother­
apy is to consider physiotherapy, as defined by the Royal
Charter, as the four pillars of practice of:
• massage;
• exercise and movement;
• electrotherapy;
• kindred methods of treatment (CSP 2008).
 The responsibilities of being a physiotherapist
The acquisition of these knowledge, skills and attri­
butes from qualifying programmes, and subsequently on
qualification through a range of learning activities, may
be used by physiotherapists to benefit people in a range
of specialties or patient groups, for example elite athletes,
older people, people with developmental or acquired
conditions, or people with mental health problems.
A recent definition of the Physiotherapy Framework
states that:
Physiotherapy is a healthcare profession that
works with people to identify and maximise
their ability to move and function. Functional
movement is a key part of what it means to be
healthy. This means that physiotherapy plays a
key role in enabling people to improve their
health, wellbeing and quality of life.
(CSP 2011c)
Autonomy
Autonomy, or ‘personal freedom’, is a key characteristic
of being a professional. Professional autonomy is the
application of the principle of autonomy whereby a pro­
fessional makes decisions and acts independently within
a professional context and is responsible and accountable
for these decisions and actions. Thus, it is both a privi­
lege and a responsibility allowing independence whilst
mirrored by responsibility and accountability for action.
Central to the practice of professional autonomy is clini­
cal reasoning, described as the ‘thinking and decision-
making processes associated with clinical practice’ (Higgs
and Jones 1995).
Clinical reasoning requires the ability to think critically
about practice, to learn from experience and apply that
learning to future situations. It is the relationship between
the physiotherapist’s knowledge, his or her ability to
collect, analyse and synthesise relevant information (cog­
nition), and personal awareness, self-monitoring and
reflective processes, or metacognition (Jones et al. 2000).
A key element of professional autonomy is for a physio­
therapist to understand and work within the limits of their
personal competence and scope of practice. Physiothera­
pists are responsible for seeking advice and guidance to
inform decision-making and action from others through
appropriate forms of professional supervision and
mentorship.
Professional autonomy has to be balanced with the
autonomy patients have to make their own decisions, that
is, patient autonomy. It is the responsibility of a profes­
sional to understand and facilitate this. Patient-centred
decisions require a partnership between patient and
professional, sharing information, with the treatment
of patients’ values and experience as equally important
as clinical knowledge and scientific facts (Ersser and
Atkins 2000).
Chapter 1
Neither physiotherapy students nor support workers
hold professional autonomy. Both groups undertake
physiotherapy-related activity with appropriate forms of
supervision. The qualifying programme that physiother­
apy students undertake prepares them for the responsi­
bilities of professional autonomy on qualification. This
preparation includes developing the knowledge, skills,
understanding and attributes necessary to accept this
responsibility. Although not autonomous practitioners,
physiotherapy support workers assume responsibility for
undertaking the tasks delegated to them in delivering a
physiotherapy service.
Person-centred practice
The professional is characterised as a person with special­
ised knowledge that can be shared with the patient in a
reciprocal ‘working with’ rather than ‘doing to’ relation­
ship, and as someone who ‘accompanies the patient on
their journey towards health, adjustment, coping or death’.
Higgs and Titchen (2001) describe the notion of the
professional’s role as a ‘skilled companion’. This patient-
centred model facilitates the sharing of power and re­­
sponsibility between both professional and patient.
Person-centred practice is an approach to healthcare
within which the goals, expectations, preferences, capac­
ity and needs of individuals (patients, clients, service
users) and their carers are central to all decision making
and activity. There needs to be an open partnership
between the physiotherapist and the patient, and an
acceptance and understanding that, at times, the view of
an individual will conflict with the view of the physio­
therapist, the profession or the organisation within
which a service is being delivered. Furthermore, individ­
ual patients will vary as to the degree to which they
intend to exercise their autonomy and the physiothera­
pist may be required to advocate for them on their
behalf.
Examples of person-centred practice include ensuring
that an individual’s perspective is listened to and reflected
at all points of intervention and service delivery; ensuring
an individual is fully involved in planning, engaging and
evaluating their experience and the outcomes of physio­
therapy; and actively seeking user involvement to inform
how a service is developed and delivered to maximise its
effectiveness.
Making a commitment to assist
those in need
As stated earlier, one of the characteristics of a professional
is to want to ‘do good’. This is reflected in the ethical
principles of the physiotherapy profession, where there is
a ‘duty of care’ incumbent on the physiotherapist towards
the patient, to ensure that the therapeutic intervention is
intended to be of benefit. This is a common-law duty, a
5
 Tidy’s physiotherapy
breach of which (negligence) could lead to a civil claim
for damages.
More generally, Koehn (1994) suggests professionals
are perceived to have moral authority, or trustworthiness
if they:
• use their skills in the context of the client’s best
interests and ‘doing good’;
• are willing to act for as long as it takes to achieve what
was set out to be achieved or for a decision to be made
that nothing more can be done to help the client;
• have a highly developed internalised sense of
responsibility to monitor personal behaviour, for
example by not taking advantage of vulnerable
patients;
• demand from the client the responsibility to provide,
for example, sufficient information to allow
decisions to be made (compliance);
• are allowed to exercise discretion (judgement) to do
the best for the client, within limits.
Principle 1 of the Code (CSP 2011a) requires that
members demonstrate appropriate professional auton­
omy and accountability. In doing so members are
expected to:
1.1.1. Use their professional autonomy to benefit others;
1.1.2. Understand and accept the significant
responsibility that professional autonomy brings;
1.1.3. Accept and uphold their duty of care to
individuals;
1.1.4. Are responsible and accountable for their
decisions and actions, including the delegation of
activity to others;
1.1.5. Justify and account for their decisions and actions;
1.1.6. Ensure that their activity is covered by appropriate
insurance.
Scope of practice
As a professional body, the CSP defines the scope of
practice for physiotherapy in the UK. In doing so it recog­
nises that UK physiotherapy is diverse, and ‘requires a
dynamic, evolving approach to scope to ensure the profes­
sion is responsive to changing patient and population
needs and that its practice is shaped by developments in
the evidence base’. In taking this approach it ‘enables the
profession to initiate, lead and respond to changes in
service design and delivery, and to optimise opportunities
for professional and career development, while being sen­
sitive to the roles and activities of other professions and
occupational groups’ (CSP 2011c). Scope of practice relates
strongly to competence and professionalism.
This concept of scope recognises that:
• the profession’s scope of practice is evolving, and
needs to evolve, in line with changing patient and
population needs, developments in the evidence
base, changes in service design and delivery, and
6
changing opportunities for professional and career
development;
• practice includes a diversity of activity that is shaped
by the collective, shared principles and thinking of
the profession;
• individuals have a responsibility to limit their
activity to those areas in which they have established
and maintained their competence;
• individuals need to evaluate and reflect on their
personal activity, taking account of the profession’s
evolving evidence base, and respond appropriately to
their learning and development needs;
• individual competence changes and shifts as they
progress through their physiotherapy career;
• individuals have a responsibility to be aware of how
their practice may challenge the boundaries of the
scope of practice of UK physiotherapy and to take
appropriate action (CSP 2011d).
Every physiotherapist has her or his own personal ‘scope
of practice’ (CSP 2011c) – that is, a range (or scope) of
professional knowledge and skills that can be applied
competently within specific practice settings or popula­
tions. When a person is newly qualified, this scope will be
based on the content of the pre-qualifying course, but will
also be informed by the individual’s experience in clinical
placements and the amount of teaching and reflective
learning that has been possible as part of those place­
ments. As a career progresses, and as a result of CPD and
personal interest, these skills and knowledge evolve with
a physiotherapist developing some skills, adding new
skills and possibly losing competence in some areas. It is
the responsibility of the professional to understand his or
her personal scope of practice as it changes and evolves
throughout their career. To practise in areas in which a
physiotherapist is not competent puts patients at risk
and is a breach of the HCPC standards (HCPC 2007,
HCPC 2008).
For example, some physiotherapists will become com­
petent in highly skilled areas such as intensive care proce­
dures or splinting for children with cerebral palsy, which
are unlikely to have been taught prior to qualification.
Others will extend their skills in areas in which they
already had some experience, for example in the manage­
ment of neurological conditions. Others will extend their
scope to become experts in a specific clinical area and
advance their skills of clinical reasoning by participating
in research, teaching or management of complex condi­
tions, or undertaking clinical specialist, advanced practice
or consultant roles (CSP 2002d).
Competence
Competence is the synthesis of knowledge, skills, values,
behaviours and attributes that enable physiotherapists to
work safely, effectively and legally within their particular
scope of practice at any point in time (CSP 2011a).
 The responsibilities of being a physiotherapist
Competence changes as a physiotherapist progresses
through their career and relates to an individual’s profes­
sional and life experiences, learning from reading, from
evaluating practice and from reflecting on practice, or
through more formal ways of learning. Competence in
some areas will increase while competence in others will
decrease or be lost. To maintain competence a physiother­
apist must engage in structured, career-long learning and
development to meet their identified learning needs.
Physiotherapists have a duty to keep up to date with
new information generated by research, with what their
peers are thinking and doing, and by formally evaluating
the outcome of their practice. The responsibility for this is
dictated by the HCPC (2008) and reflected in the Quality
Assurance Standards for Physiotherapy Service Delivery
(CSP 2012). For example, Section 3 Learning and Develop­
ment includes a number of Standards including Standard
3.1 Members actively engage with and reflect on the con­
tinuing professional development (CPD) process to main­
tain and develop their competence to practise.
Responsibility to patients
This chapter has already discussed the importance of the
individual physiotherapist, as well as the profession as a
whole in maintaining the attributes of professionals.
Koehn (1994) argues that trustworthiness is what stands
out as a particularly unique characteristic of being a pro­
fessional – to do good, to have the patient’s best interests
at heart and to have high ethical standards.
Trust is, perhaps, the most essential characteristic
with which to develop a sense of partnership with patients
that, in turn, will optimise the benefits of intervention.
For physiotherapy, many of the other hallmarks for build­
ing and securing trust are set out in the QA standards
(CSP 2012).
Responsibility to those who pay   tered (registrants) with the HCPC may call themselves a
for services
Physiotherapists have an ethical responsibility to payers of
services, whether these are commissioners of healthcare,
purchasers of services, taxpayers or individual patients, to
provide efficiently delivered, clinically- and cost-effective
interventions and services in order to provide value in an
era when resources for healthcare are limited.
Responsibility to colleagues and   performance and ethics (HCPC 2008) and profession-
the profession
A profession has legitimate expectations of its members
to conduct themselves in a way that does not bring the
profession into disrepute, but rather enhances public
perception of it. Physiotherapists have a duty to inform
themselves of what is expected of them. Indeed, the
Chapter 1
expectation of the CSP is that members adhere to
the Code (CSP 2011a), and this commitment forms part
of the contract of membership of the CSP. Similarly,
the CSP expects that all members should meet the Quality
Assurance Standards for Physiotherapy Service Delivery
(CSP 2012). Where they do not, programmes of profes­
sional development should be put in place to facilitate
full compliance, as part of the individual’s professional
responsibility.
Physiotherapists are encouraged to be proactive in sup­
porting each other’s professional development and in pro­
moting the value of the profession in local workplace
settings, in policy-making forums and in the media. Physio­
therapists should not be critical of each other except in
extreme circumstances. However, they do have a duty to
report circumstances that could put patients at risk. In
the NHS there are procedures and a nominated officer
within each trust from whom advice can be sought.
Outside the NHS, advice can be sought from the CSP.
BELONGING TO A PROFESSION
Regulation: The Health and Care
Professions Council (HCPC)
The Health Professions Council (HPC) was created by the
Health Professions Order 2001 (HCPC 2001) as the statu­
tory regulator of 13 professions, including physiotherapy.
The regulatory process is a government measure to protect
patients and the public from unqualified or inadequately
skilled healthcare providers. As the number of professions
increased to 17, it was renamed the Health and Care
Professions Council (HCPC) in 2012 to reflect the diver­
sity of the professions regulated.
In the UK, the titles ‘physiotherapist’ and ‘physical
therapist’ are protected and only physiotherapists regis­
physiotherapist or physical therapist. As the title is pro­
tected, a physiotherapist listed does not, therefore, need
to place HCPC after their name as this is implicit within
the title.
The HCPC sets standards of professional training, per­
formance and conduct for the 17 regulated professions
and maintains a public register of health professionals
that meet its standards. The HCPC publishes generic
standards for HCPC registrants, standards of conduct,
specific standards (Standards of Proficiency Physiothera­
pists, HCPC 2007), which members are required to and
agree to meet. Registrants are required to keep up to date
with the processes and requirements decreed by the
HCPC. The HCPC only regulates the practice relating to
humans and does not include regulation of physiothera­
pists practising on animals.
7
 Tidy’s physiotherapy
In 2006, the HCPC put in place a system requiring
re-registration at intervals of two years (HCPC 2011).
Re-registration was introduced partly in response to a
lessening of public confidence in the NHS following,
for example, the report into children’s heart surgery in
Bristol (Bristol Royal Infirmary Inquiry 2001). Equally
disturbing were the revelations about the murders of
so many patients by Harold Shipman, a man who had
previously been a trusted general practitioner (GP),
where health systems failed to detect an unusually high
number of deaths (DH 2004).
These measures demonstrate a commitment to protect­
ing the public through more explicit and independent
processes (DH 2002). The re-registration process is linked
to an individual’s commitment to continuous professional
development (CPD), whereby individuals must undertake
and maintain a record of their CPD activities and, if
required, submit evidence of this and its outcomes to their
practice, service users and service. The process of re-­
registration aims to identify poor performers who may be
putting the public at risk, as well as providing an incentive
for professionals to keep up to date, maintaining and
further developing their scope of practise and competence
to practise.
The HCPC takes action when complaints are received
and if registered health professionals, including physio­
therapists, do not meet these standards (HCPC 2005). The
process of registration and the accessible public register
provide assurance to the public that a physiotherapist is
legally allowed to practise. Disciplinary processes are in
place to ultimately remove an individual from the register
(HCPC 2005) where necessary.
While the principles of professionalism should be
aspired to by physiotherapists anywhere in the world, the
existence and/or role of regulators and professional bodies
in the locations of practice when outside the UK may
vary depending on political, social and financial factors.
Professional membership:   of Professional Values and Behaviour (CSP 2011a). A con­
the Chartered Society of
Physiotherapy (CSP)
The CSP is the professional body and therefore the primary
holder and shaper of physiotherapy practice. As such, it is
the guardian of the profession’s body of knowledge and
skills and a number of activities emanate from this. The
CSP works on behalf of the profession to protect the
chartered status of physiotherapists’ standing, which is
one denoting excellence. The CSP provides a breadth
of support and resources to support members in their
working lives whereby its education and professional
activity is centred on leading and supporting members’
delivery of high-quality, evidence-based patient care and
establishing a level of excellence for the profession.
8
As the guardian of the profession’s body of knowledge
and skills in the UK, the CSP aims to:
• uphold the credibility, values and high standards of
the UK physiotherapy profession;
• ensure new areas of physiotherapy practice draw on
the profession’s distinctive body of knowledge and
skills, and uphold a physiotherapist’s accountability
for their decision-making and actions;
• enhance the profession’s contribution across the UK
health and well-being economy;
• optimise the profession’s ongoing development;
• ensure the profession’s movement into a new area of
practice is in the interests of the population and
patient groups that it serves (or can potentially
serve), while being sensitive to the roles and activities
of other professions and occupational groups;
• ensure that the profession’s decision to recognise a
particular area of practice can be explained and justified
in terms of that area’s safety, effectiveness and efficacy;
• maintain a record of how the UK physiotherapy
profession practice has evolved (CSP 2008).
The relationship between the HCPC and the CSP is
essential and, although registration with the HCPC enables
a registrant to call themselves a physiotherapist, it is only
those physiotherapists who are members of the CSP who
may call themselves a chartered physiotherapist and use
the letters MCSP.
The CSP continues to handle complaints or consider
matters of fitness to practise concerning members of the
Society who are not regulated by the HCPC, including
physiotherapists treating animals, students and the CSP’s
associate members. The CSP also holds a disciplinary func­
tion to those members who are registrants of the HCPC.
Code of professional values  
and behaviour
In 2011, the CSP’s Council approved the new CSP Code
dition of membership is that all members – qualified
members, students and associate members – must agree
to meet the Code. The Code defines the values and behav­
iour that the CSP expects of its members and that under­
pin their physiotherapy roles and activity. It has been
developed to support members in taking responsibility
for their actions and to promote their professionalism.
Throughout, it reinforces the need for members to meet
the requirements of regulation, the law, and their employ­
ing organisations and education institutions.
The principles are that:
1. members take responsibility for their actions;
2. members behave ethically;
3. members deliver an effective service;
4. members strive to achieve excellence (CSP 2011a).
 The responsibilities of being a physiotherapist
Each of these principles is expanded on in sets of layered
statements and underpinned by healthcare ethics, values
and professional concepts. The Rules of Professional
Conduct (the Rules) (CSP 2002a) were endorsed at the
very first council meeting of the CSP in 1895 (Barclay
1994). They have been revised and updated at intervals
since and have now been superseded by the Code in setting
out the expectations of the CSP. The Rules defined
the professional behaviour expected of chartered physio­
therapists and were founded to safeguard patients.
However, they remain for the purpose of supporting the
byelaws and taking action against those members who
are not regulated by the HPC; that is, students, assistants
(associate members) and qualified members practising on
animals.
Quality Assurance Standards for
Physiotherapy Service Delivery
The CSP initially agreed and published national standards
in 1990 which were subsequently revised in 2000 and
2005 (CSP 2005a). The standards underwent a significant
revision in 2012 (CSP 2012) to reflect contemporary
healthcare and the increasing expectations of the public to
be active partners in their healthcare. The standards place
greater emphasis on the role of the standards in quality
assurance, the integration of members’ roles in clinical
practice and service delivery and their application to all
members of the CSP: physiotherapists, students and asso­
ciate members.
The CSP QA standards include two resources: the
Quality Assurance Standards for Physiotherapy Service
Delivery and the Quality Assurance Audit tool (CSP 2012).
They are grouped into 10 sections with each section
including a number of standards. Each standard then
includes a number of measurable criteria which identify
how the standards may be met. These measurable criteria
enable the comparison of actual performance with the
standard through clinical audit.
The standards are organised into 10 sections and provide
detailed statements which support members in meeting
the expectations of the CSP articulated in the Code and,
for physiotherapists, the standards of the HCPC. Patients
and service users accessing these have detailed informa­
tion on the standards of physiotherapy service delivery
they can expect.
Physiotherapy Framework
The Physiotherapy Framework (CSP 2011c) has been
designed to promote and develop physiotherapy practice
and complements the Code, CSP standards and HCPC
standards.
The framework defines and illustrates the knowledge,
skills, behaviour and values required for contemporary
Chapter 1
physiotherapy practice: describing physiotherapy
practice:
• at all levels – from a new support worker through to
a senior level registered physiotherapist;
• across a variety of occupational roles – clinical,
educational, leadership, managerial, research and
support;
• in a variety of settings – in health and social care,
in industry and workplaces, in education and
development, and in research environments;
• across all four nations of the UK.
The framework supports CSP members’ professional
practice in a number of different ways and demonstrates
how physiotherapy works to maximise individuals’ poten­
tial – through its clinical, educational, leadership and
research practice.
Physiotherapy education
programmes
The CSP provides a set of principles on which physiother­
apy qualifying programmes should be based in order to
obtain CSP accreditation. These principles are intended
to help course providers develop their programmes to
prepare their learners for current and emerging physio­
therapy roles that meet changing healthcare needs and
for practice within an evolving context. For example,
Principle 1, Programme Outcomes Qualifying, identifies
that ‘programmes should aim to develop the knowledge,
skills, behaviour and values (KSBV) required to practise
physiotherapy at newly qualified level (NHS Band 5 or
equivalent), while nurturing the skills, behaviour and
values that will enhance career-long development and
practice’ (CSP 2011c).
Physiotherapy programmes must meet these re­­
quirements to be approved by the CSP on behalf of the
profession. Physiotherapists completing an approved pro­
gramme are eligible for membership of the CSP as chartered
physiotherapists and, as members, may use the letters
MCSP. The Learning and Development Principles for
CSP Accreditation of Qualifying Programmes in Physio­
therapy 2011 (CSP 2011b) replace the Curriculum Frame­
work for Qualifying Programmes in Physiotherapy
published in 2002 (CSP 2002b).
DELIVERING SAFE AND EFFECTIVE
PHYSIOTHERAPY SERVICES:
CLINICAL GOVERNANCE
So far, this chapter has explored the responsibilities of
being a physiotherapist from a professional perspective
with the focus on the individual’s personal responsibility
9
 Tidy’s physiotherapy
Definition
Clinical governance is a framework through which NHS
organisations are accountable for continuously improving
the quality of their services and safeguarding high
standards of care by creating an environment in which
excellence in clinical care will flourish (Secretary of State
for Health 1998).
[While this definition has been used in England, similar
interpretations of the term have been made in Scotland,
Wales and Northern Ireland.]
as a professional. This section describes the context of a
professional’s responsibilities to the organisation within
which they undertake their professional role, whether in
the public or independent sector.
Clinical governance provides a framework for ensuring
the safety, quality and effectiveness of services. Although
in the NHS, for example, clinical governance is the respon­
sibility of NHS trusts, its foundation, based on ‘the prin­
ciple that health professionals must be responsible and
accountable for their own practice’ (Secretary of State for
Health 1998) is relevant regardless of the sector where
services are delivered and clinical governance processes are
in place throughout health and social care.
It can be argued that clinical governance is, at least in
part, a response to the loss of public confidence in the
NHS, as discussed earlier, which has undermined public
perceptions of the NHS as an organisation they can rely
on to ‘do good’ and of the government to protect the
public. Clinical governance has a key role in assuring
and re-building the public’s confidence in health services,
providing high-quality and effective care and, above
all, reducing the risk of harm through negligence, poor
performance or system failures.
A number of key themes were introduced as part of
clinical governance:
• the accountability and statutory responsibility of
chief executives for quality;
• the introduction of a philosophy of continuous
improvement;
• emphasis on an integrated approach to healthcare
whereby the whole system of care is examined
crossing professions, departments, organisations and
sectors to ensure the whole process meets the needs
of patients;
• an aspiration to achieve consistency of services
across the NHS;
• an emphasis on CPD and life-long learning (LLL) for
all healthcare workers in order to keep up to date
and deliver high-quality services.
10
Examples of activities within a clinical
governance programme
• Ensure physiotherapists are on the HCPC register.
• Consider and learn from patient feedback and
complaints.
• Carry out programmes for quality improvement,
including clinical audit and evaluation, and report
how these have led to improvements for patients.
• Ensure that nationally-produced, high-quality
standards and clinical guidelines are implemented
locally.
• Have an appropriate skill mix and staffing level to
ensure the safety of patients, making appropriate use
of human and financial resources in order to provide
effective care.
• Have a process for identifying and supporting staff
members whose competence is in question.
• Provide an in-service training programme and time for
individual CPD activities.
• Ensure appropriate participation in multi-professional
clinical audit and quality improvement activities.
Clinical governance should be considered as a package of
measures which include:
• openness;
• risk management;
• clinical effectiveness including evidence-based
practice, standards and guidelines;
• research and development;
• clinical audit and evaluating the effectiveness and
quality of services;
• information management;
• education and training including continuing
professional development/life-long learning to
ensure the skill mix is appropriate.
Those responsible for physiotherapy service delivery,
for example, physiotherapy managers, are responsible for
devising, implementing and reporting a departmental
clinical governance programme, which should reflect
all the aspects of clinical governance. Physiotherapists
should play an active part in contributing to physiotherapy
clinical governance programmes and also participate in
relevant multi-professional clinical governance activities
such as clinical audit or local protocol/clinical pathway
design.
Evidence-based practice
There is information to show that evidence-based medi­
cine was in place as long ago as the 1940s, and it was
Professor Archie Cochrane in 1972 who first introduced
 The responsibilities of being a physiotherapist
the concept of evidence-based medicine (Cochrane 1972).
However, until the early 1990s ‘evidence’ was largely
based on personal experience and opinions derived from
that experience, together with the experience of colleagues
or those perceived to be experts and opinion leaders.
In 1991, Sir Michael Peckham, then Director of Research
and Development for the Department of Health (DoH at
the time; changed to DH in 2004), noted that ‘strongly
held views based on belief rather than sound information
still exert too much influence in healthcare. In some
instances the relevant knowledge is available but is not
being used; in other situations additional knowledge
needs to be generated from reliable sources’ (DH 1991).
At about the same time, a relatively small group of doctors
began to write about evidence-based medicine.
Definition
An early definition of evidence-based medicine stated
that it is the ‘conscientious, explicit and judicious use of
current best evidence in making decisions about the care
of individual patients’ (Sackett et al. 1996).
A more recent definition of evidence-based practice is
‘decisions about healthcare are based on the best
available, current, valid and relevant evidence. These
decisions should be made by those receiving care,
informed by the tacit and explicit knowledge of those
providing care, within the context of available resources’
(Dawes et al. 2005).
The CSP QA standards state the following within Section
8 Physiotherapy management and treatment:
• 8.2. There is a system to ensure that physiotherapy
care is based on the best available evidence of
effectiveness.
• 8.5. Appropriate treatment options are identified
based on the best available evidence, in order to
deliver effective care (CSP 2012).
A range of evidence is available to inform practice and
a hierarchy of evidence is often described or used in the
literature. This ranges from (Ia) systematic reviews, in
which evidence on a topic has been systematically identi­
fied, appraised and summarised according to predeter­
mined criteria (usually limited to randomised controlled
trials (RCTs)) – said to be the strongest evidence (the most
reliable estimate of effectiveness) – to (IV) expert opinion,
perceived as the least reliable. An example is shown in
Table 1.1.
Research takes many forms and is not the only form of
evidence. For some questions, such as the efficacy of par­
ticular drugs, or a particular modality, such as exercise
programmes for the management of back pain, research
Chapter 1
Table 1.1  A hierarchy of evidence
Level Type of evidence
Ia Evidence obtained from a systematic review or
meta-analysis of RCTs
Ib Evidence obtained from at least one RCT
IIa Evidence obtained from at least one well-
designed controlled study without
randomisation
IIb Evidence obtained from at least one other type
of well-designed, quasi-experimental study
III Evidence obtained from well-designed,
non-experimental descriptive studies, such as
comparative studies, correlation studies and
case studies
IV Evidence obtained from expert committee
reports or opinions and/or clinical experience of
respected authorities
Adapted from NICE (2001).
studies that compare one intervention with another or a
placebo (RCTs) can provide reliable information about the
degree to which an intervention is effective. But other
forms of evidence are also important (Figure 1.1). What
patients tell us about their condition, which treatments
they find effective and the degree to which interventions
improve their ability to get on with their lives also provide
important evidence. The physiotherapist also contributes
to evidence in the form of clinical expertise, derived from
clinical reasoning experience. Thinking and reflecting
during or after a clinical encounter will develop such
expertise (Jones et al. 2000). Knowledge which arises from
and within practice (practice-based and practice-generated
knowledge) will become part, along with research evi­
dence, of your rationale for practice (Higgs and Titchen
2001). Sackett and colleagues reflected this in concluding
their definition that evidence-based practice requires
integration of ‘clinical expertise with best available exter­
nal clinical evidence from systematic research’ (Sackett
et al. 1996).
The hierarchy does not, therefore, recognise that differ­
ent research methods are needed to answer different types
of questions and that, while a qualitative study may be the
best research method for a particular question, it still
receives a low rating. It also fails to recognise the impor­
tance of expertise derived from clinical reasoning experi­
ence, discussed above. Physiotherapists should consider
contributing to an ongoing debate to develop a hierarchy
that reflects more appropriately a patient-centred approach
to identifying the relevant evidence.
11
 Tidy’s physiotherapy
Published
Research
evidence
Evidence-based
Knowledge practice
Interaction
Patient
Past experience,
Preferences beliefs and values
Figure 1.1  What do we mean by ‘evidence’? (Adapted from Bury (1998), with permission.)
The following steps will be useful in identifying and
using research evidence:
• Consider the clinical question for which an answer is
sought in the information search. Identify the
population (e.g. people with multiple sclerosis with
symptoms of urinary incontinence), the intervention
(e.g. neuromuscular electrical stimulation) and the
outcome sought (e.g. a reduction in symptoms), and
use this information to formulate a search strategy.
• Work in partnership with an information scientist to
get the best results from a literature search (their
information skills and knowledge combined with
your clinical skills and knowledge).
• Look first for evidence that has already been
synthesised – systematic reviews, nationally-
developed clinical guidelines or standards. This will
save time looking for individual studies; if it is a
high-quality synthesis, it will also provide a more
reliable estimate of effectiveness.
• Know the databases well enough to know which
will have the most relevant information for any
particular topic.
• Check the titles and abstracts for relevance.
• Critically appraise any relevant papers found to
assure their quality and the reliability of their
conclusions (a list of appraisal instruments can be
found at the end of this chapter).
• When the ‘best available evidence’ has been found,
consider it in relation to the patient and past
experience. Is it appropriate for that patient? Can the
degree of likely benefits and harms (if any) be
quantified?
• Discuss the evidence with the patient and agree
together the preferred intervention(s).
• Implement the preferred intervention(s).
12
Unpublished
Skills and
knowledge
Clinical expertise
Clinical reasoning,
practice-generated
knowledge
• Evaluate the effect of the intervention(s) and act
accordingly.
More information about evidence-based practice can be
found in Herbert et al. (2005) or at www.nettingtheevidence
.org.uk, a catalogue of useful electronic learning resources
and links to organisations that facilitates evidence-based
healthcare. See also ‘Sources of Critical Appraisal Tools’
towards the end of this chapter.
Clinical effectiveness
Clinical effectiveness, as defined by the DH, sounds very
much like evidence-based practice – doing things known
to be effective for a particular patient or group of patients.
But the fact that an intervention has been shown to work
in research studies, in a relatively controlled environment,
does not necessarily mean that it will work for a particular
patient. Both patients and practitioners are unique beings
and there are many additional factors, practical and behav­
ioural, that need to be considered to ensure the patient
gets the maximum benefit from an intervention.
While evidence-based practice is a key component
of clinical effectiveness, clinical effectiveness also takes
account of a range of other influences that could affect the
patient’s ability to benefit from an intervention based on
high-quality research evidence.
Definition
Clinical effectiveness was defined by the DH in 1996 as
‘the extent to which specific clinical interventions, when
deployed in the field for a particular patient or population,
do what they are intended to do – that is, maintain and
improve health and secure the greatest possible health
gain from the available resources’ (NHS Executive 1996).
 The responsibilities of being a physiotherapist
The following questions will give an insight into the
patient’s ability to benefit from an intervention. The ques­
tions serve to illustrate the complexity of the clinical reas­
oning process, where highly skilled judgements have to be
made based on consideration of the whole person, physi­
cally, emotionally and within society, as well as the envi­
ronment, practitioner skills and resources available in
order to provide truly effective physiotherapy manage­
ment and treatment.
• Who should manage the patient? Is physiotherapy
the most relevant approach and, if so, who should
treat the patient? Does the individual physiotherapist
have the skills and knowledge?
• Why is physiotherapy or a specific intervention
indicated or identified?
• What is the most appropriate intervention?
• Which approach is the most appropriate? Does this
consider the patient as an individual in terms of
lifestyle? Does patient have an opportunity to fully
describe the symptoms and the impact of the problem
on the person’s life, and to ask questions? Does the
patient have enough information to be able to give
consent? Are other options discussed, that may be
more acceptable to the patient, even if less effective?
• Where should the patient be managed? Is the setting
for treatment most appropriate, e.g. treatment in a
hospital setting may mean a long, exhausting and
expensive journey for the patient?
• When should intervention begin? Does the patient
have adequate privacy, warmth and comfort during
treatment? How long does the patient have to wait
for treatment – will any delay affect the effectiveness
of the interventions?
Standards
One of the tenets of clinical governance is consistency –
for the public, being confident that they will experience
the same quality of care regardless of where it is delivered.
The availability of high-quality national standards, the use
of these locally and the evaluation of their implementa­
tion, should ensure an improvement in the standards of
service delivery, by identifying where actual services are
falling short of the standards and action needs to be taken.
Physiotherapists have a key role in implementing stand­
ards in the services they provide to the relevant patient
population. Implementation will also provide opportuni­
ties to promote the value of physiotherapy to this patient
population and highlight the contribution physiothera­
pists can make to a trust’s compliance with this particular
standard. Two examples of these are set out below.
Nationally-developed standards
The CSP’s Quality Assurance Standards for Physiotherapy
Service Delivery (CSP 2012) are one example of
Chapter 1
nationally-developed standards. Others are derived from
nationally-agreed guidelines or guidance documents,
for example those produced by CSP Professional Net­
works. There is some evidence to suggest that nationally-
developed standards or clinical guidelines are likely to be
more robustly developed (Sudlow and Thomson 1997)
than those developed locally, and that their universal
implementation locally will ensure consistency and
effectiveness.
National Service Frameworks
National Service Frameworks (NSFs) and strategies are a
government initiative which are based on the best availa­
ble evidence of what treatments and services work most
effectively for patients.
The NSFs aim to address the ‘whole system of care’ and
each sets out where care is best provided and the standard
of care that patients should be offered in each setting.
They provide ‘a clear set of priorities against which local
action can be framed’ and seek to ensure that patients will
get greater consistency in the availability and quality of
services, right across the NHS (Secretary of State for
Health 1998).
Each strategy is developed in partnership with health
professionals, patients, carers, health service mangers, vol­
untary agencies and other experts. They set clear quality
requirements for care including explicit standards and
principles for the pattern and level of services required for
a specific service or care group. A range of NSFs has been
developed, for example Cancer Strategy, Framework for
Coronary Heart Disease, National Strategy for COPD
(chronic obstructive pulmonary disease), Diabetes Quality
Standards, Setting Standards for Kidney Care, Framework
for Long-term Conditions, Mental Health Strategy, Frame­
work for Older People and Standards for Stroke Care.
Clinical guidelines
Definition
Clinical guidelines are ‘systematically developed
statements to assist practitioner and patient decisions
about appropriate healthcare for specific circumstances’
(Field and Lohr 1992).
The key factors in the development of clinical guidelines
are the systematic process for identifying and quality-
assessing research evidence, and the systematic and trans­
parent process used for the interpretation of the evidence
in the context of clinical practice, in order to formulate
reliable recommendations for practice. A number of exam­
ples are provided below.
13
 Tidy’s physiotherapy
CSP endorsed guidelines
The physiotherapy profession has developed a number
of national, physiotherapy-specific clinical guidelines. For
users of clinical guidelines, CSP-endorsed clinical guide­
lines can be considered of high quality and should be
implemented locally. To ensure quality and provide con­
fidence for users and in response to guidelines submitted
to the CSP, the CSP has established a process for the
endorsement of these clinical guidelines which is part
of the programme Supporting Knowledge in Physiother­
apy Practice (SKIPP). The criteria for assessing whether
the quality of a guideline warrants CSP endorsement
can be found in an appraisal questionnaire developed
by an European consortium known as the AGREE instru­
ment (AGREE: www.agreetrust.org). Further information
about the process for the development of clinical guide­
lines in physiotherapy is available from the CSP website
(www.csp.org.uk).
National Institute for Health and Clinical
Excellence (NICE)
NICE is an independent organisation established by the
government in 1999 to provide health and social care
professionals and the public in England and Wales with
information to promote good health and prevent ill-
health, together with information about the clinical-
and cost-effectiveness of healthcare.
NICE provides evidence-based national guidance for
the NHS, local authorities, charities and those with a re­­
sponsibility for commissioning or providing healthcare,
public health or social services with the aim of promoting
quality of care. NICE also provides support and a range of
resources for putting this into practice.
The DH and the Assembly for Wales have given
NICE the remit for developing ‘robust and authoritative’
clinical guidelines, taking into account clinical and cost-
effectiveness (NICE 2001). More information about the
key principles that underpin the way NICE approaches
clinical guideline development can be found on its website
(www.nice.org.uk). One of its work programmes is to
develop clinical guidelines, which is carried out by a series
of collaborating centres.
Scottish Intercollegiate Guidelines Network
The Scottish Intercollegiate Guidelines Network (SIGN)
was formed in 1993. Its objective is to improve the quality
of healthcare for patients in Scotland by reducing variation
in practice and outcome through the development and
dissemination of national clinical guidelines. These guide­
lines contain recommendations for effective practice based
on current evidence. Further information can be found on
its website (www.sign.ac.uk).
14
Care Quality Commission (CQC)
The Care Quality Commission (CQC) is the independent
regulator of health and social care in the UK. It replaced
the Healthcare Commission in 2009. This statutory body
was established to raise standards of care provided by the
NHS, local authorities, private companies and voluntary
organisations throughout England and Wales, and defines
its role as ‘Checking that hospitals, care homes and care
services are meeting our standards’.
The CQC has the role of assessing the implementation
of clinical governance in every NHS trust and making its
findings public. Teams of trained reviewers visit trusts (and
can be called in at any time should concerns be raised)
to review trust information and data, talk to staff and
patients, and consider the trust’s performance in specified
categories. In Scotland a similar function is provided by
NHS Quality Improvement Scotland and in Northern
Ireland the Health and Personal Social Services Regulation
and Improvement Authority (HPSSRIA) undertakes regu­
lar reviews of the quality of services.
EVALUATING SERVICES
The professional responsibility of a physiotherapist in­­
cludes knowing whether or not a service or an intervention
is effective. This is reflected in both the Code and CSP QA
standards. Several of the CSP’s QA standards (CSP 2012)
of physiotherapy practice include criteria that relate to
evaluation, including:
• Standard 3.1. Members actively engage with and
reflect on the continuing professional development
(CPD) process to maintain and develop their
competence to practise;
• Standard 8.4. Analysis is undertaken following
information gathering and assessment in order to
formulate a treatment plan, based on the best
available evidence;
• Standard 8.6. The plan for intervention is constantly
evaluated to ensure that it is effective and relevant to
the service user’s changing circumstances and health
status;
• Standard 9.1. Effective quality improvement
processes are in place, which are integrated into
existing organisation-wide quality programmes;
• Standard 9.2. There is a clinical audit programme to
ensure continuous improvement of clinical quality
with clear arrangements for ensuring that clinical
audit monitors the implementation of clinical
effectiveness;
• Standard 9.4. The effect of the physiotherapeutic
intervention and the treatment plan is evaluated to
ensure that it is effective and relevant to the goals.
 The responsibilities of being a physiotherapist
The central tenet of evaluation is learning from the
process and outcome which leads to improvements in the
quality and effectiveness of practice. Evaluation of services
and practice should be carried out and the results used in
the context of CPD and reflective practice, to improve an
individual practitioner’s personal practice and/or the
delivery of a whole service. Set out below are a number of
means (not mutually exclusive) by which physiotherapists
can evaluate their practice.
Clinical audit
Clinical audit is a cyclical process which enables the
comparison of actual practice or service delivery against
standards or criteria based on the ‘best available evi­
dence’ of effectiveness. In undertaking audit, a reliable
benchmark with which to compare practice is required.
Earlier, the importance of the local implementation of
nationally-developed standards and evidence-based clini­
cal guidelines was discussed. These provide such a relia­
ble benchmark.
Definition
Clinical audit is a cyclical process involving the
identification of a topic, setting standards, comparing
practice with the standards, implementing changes and
monitoring the effect of those changes (CSP 2005a).
Further information about clinical audit can be found
in New Principles of Best Practice in Clinical Audit
(Burgess 2011).
Audit has a key role in the continuous cycle of quality
improvement when the audit cycle is complete. Firstly,
through analysis of the results to identify the extent to
which those standards or criteria have been met and the
appropriateness of the chosen standards. Secondly, by uti­
lising this analysis to make recommendations to change
service delivery. And, finally, to ensure that action is taken
on these recommendations.
Patient feedback
Patient feedback is a valuable mechanism for evaluating
practice. One method is the use of a validated patient-
assessed outcome measure to provide information about
the patient’s perception of health gain, or the use of a
structured questionnaire, based on standards, to deter­
mine the patient’s perception of the quality of the treat­
ment. Responses from feedback questionnaires can be
used by individuals or services to reflect on the extent to
which the standards have being met, and to introduce new
processes or development opportunities to secure greater
conformance, if necessary.
Chapter 1
Another valuable source of patient feedback is patients’
complaints. These provide opportunities to address the
issues contained within them in order to introduce a
service improvement. Any issue that becomes a problem
for a patient is a problem for the service and should be
analysed. The involvement of the patient making the
complaint in this process, if willing, will facilitate the
finding of a solution that can then be embedded into
systems and processes.
Health outcomes
Health outcomes measure a change in the health status of
an individual or a group which can be attributed to inter­
vention. Utilising health outcomes of care will determine
the impact of the process of care or intervention on the
patient’s life by using specific measures before and
after treatment. Measures must be chosen carefully to
ensure the test, scale or questionnaire records what it
aims to record (is valid and responsive) and is sufficiently
well described to ensure that everyone who uses it
does so in the same way (is reliable). Consideration of
these factors enables the most appropriate measures for
a specific patient or patient group to be identified. Infor­
mation gathered will provide details on whether the
intervention has had the impact intended. More informa­
tion on using measures can be found on the CSP website
(www.csp.org.uk).
The information will be of interest to patients them­
selves as an objective assessment of their improvement
and is increasingly important to demonstrate the benefits
and the clinical- and cost-effectiveness of physiotherapy
services.
Patient-reported outcome  
measures (PROMs)
PROMs are measures of a patient’s health status or health-
related quality of life which are usually short ques­
tionnaires completed by the patient from the patient’s
perspective. They measure health gain and provide infor­
mation on the patient’s health and quality of life. The
information contributes to the measurement and improve­
ment of the quality of health services. These were initially
introduced for four procedures: hip replacements, knee
replacements, hernia and varicose veins. PREMS are
patient-reported experience measures. Use of these is
included in the CSP QA standards (Standard 8.3. Appro­
priate information relating to the service user and the
presenting problem is collected) (CSP 2012).
NHS outcomes framework
The first NHS outcomes framework sets out the outcomes
and corresponding indicators that will be used to hold the
15
 Tidy’s physiotherapy
NHS commissioning board to account for the outcomes
it delivers through commissioning health services from
2012/13. This framework helps understand what it means
for an NHS focussed on outcomes, and its implication
for individuals, organisations and health economies
(DH 2010b).
Peer review
Peer review provides an opportunity for a physiotherapist
to evaluate the clinical reasoning behind their decision-
making with a trusted peer. It can be applied most
effectively to the assessment, treatment planning and
evaluative components of physiotherapy practice where
the reasoning behind the information recorded in the
physiotherapy record can be explored.
CONTINUING PROFESSIONAL
DEVELOPMENT (CPD)
Definition
CPD is the work-oriented aspect of life-long learning
(LLL) and should be seen as a systematic, ongoing
structured process of maintaining, developing and
enhancing skills, knowledge and competence, both
professionally and personally, in order to improve
performance at work (CSP 2003).
Life-long learning (LLL) is a theme promoted by the
government across all sectors of the population, in order
to ensure the workforce is equipped to do the jobs that
will contribute to high-quality public services and
promote prosperity in the UK.
In healthcare, the connection between CPD/LLL and the
quality of services is at the centre of the government’s
view of a new, modernised NHS (CSP 2001).The require­
ment for re-registration of physiotherapists and other
healthcare professional discussed earlier makes CPD an
essential component of professional life (CSP 2005b).
The introduction of a philosophy of LLL and individual
responsibility for it is introduced in qualifying pro­
grammes, equipping students for a lifetime of learning in
order to maintain and continually improve their compe­
tence to practise. Written evidence of learning and devel­
opment, and its impact on improving practice, is now an
essential requirement. Every physiotherapist must estab­
lish a portfolio containing such evidence that will need to
be maintained throughout a career and is a requirement
of the HCPC.
16
The emphasis on the importance of CPD/LLL within
clinical governance is a welcome recognition. The chal­
lenge for physiotherapists to keep up to date with the fast
pace of change in healthcare is significant – in particular
the rapid increase in the volume of information that has
to be evaluated and incorporated into practice. Protected
time for CPD was recommended by the Kennedy Report
(Bristol Royal Infirmary Inquiry 2001) and has been
emphasised in the CSP QA standards (CSP 2012).
Another form of professional development is reflective
practice, a process in which practitioners think critically
about their practice and, as a result, may modify their
action or behaviour. Reflective practice is the process of
reviewing an episode of practice to describe, analyse, eval­
uate and inform professional learning. In such a way, new
learning modifies previous perceptions, assumptions and
understanding, and the application of this learning to
practice influences treatment approaches and outcomes
(CSP 2002b). ‘Reflection enables learning at a sub-
conscious level to be brought to a level where it is articu­
lated and shared with others’ (CSP 2001). Learning from
experience requires the development of skills such as self-
awareness, open-mindedness and critical analysis.
Some key characteristics of CPD (CSP 2003)
• It should comprise a broad range of learning activities
(courses, in-service education, reading, supervision,
research, audit, reflections on experience, peer review
– this is not an exhaustive list).
• It is based on individual responsibility, trust and self-
evaluation.
• It links learning with enhancement of quality of patient
care and professional excellence while ensuring public
safety.
• It should recognise the outcomes of CPD with a focus
on achievement.
SKILL MIX
As discussed earlier in the chapter, physiotherapists have
a professional responsibility to use their skills appropri­
ately and should only practise to the extent that they have
established, maintained and developed their ability to
work safely and competently. Additionally there is a pro­
fessional responsibility to use resources (human, as well
as financial) appropriately in delivering healthcare. This
means giving consideration to whether a patient should
be referred on to another professional with different or
higher level skills or to a specialist in a different clinical
area. Equally, consideration should be given to whether
 The responsibilities of being a physiotherapist
there are elements of the treatment programme that can
be delegated to a physiotherapy assistant or other support
worker.
The decision about whether to delegate, and which tasks
or activities to delegate, is entirely the responsibility of the
physiotherapist making that decision. The physiotherapist
also takes full responsibility for the application of the
tasks or activities carried out by the person who has been
delegated to. Choosing tasks to be undertaken by a support
worker is a complex element of professional activity that
depends on an informed professional opinion.
Physiotherapists need to use their own skills and knowl­
edge to carry out an assessment of a patient in order to
formulate a clinical diagnosis and a programme of treat­
ment derived from those findings. This process requires
skills of analysis and clinical reasoning – key professional
attributes. However, an appropriately trained support
worker may well have the attributes required to be able to
carry out some, or all, elements of the treatment pro­
gramme based on existing knowledge and skills. This
would include the monitoring of the patient’s condition
and progress with the plan, and advising the physiothera­
pist of any variations in either of these. As there are no
guidelines about what to delegate, the physiotherapist
should consider carefully the scope and nature of the task
and ensure this is clearly defined and communicated to
the assistant. Many organisations have specific policies
and procedures for components of physiotherapy manage­
ment undertaken by support workers and these should be
considered.
In deciding who to delegate to, factors to be considered
are the competence of the support worker and the nature
of the task. The competence of the support worker will
be affected by the individual’s knowledge, skills informed
by experience and training received. The physiotherapist
should also consider the individual situation, in terms
of the patient and specific circumstances. The support
worker, therefore, must be allowed to make an assess­
ment of his or her own competence in relation to the
particular task.
The decision about what to delegate and who to dele­
gate to is one that, while ultimately the responsibility of
the physiotherapist, also requires the active involvement
of the person to whom the task is being delegated. The
task should not be delegated if either the physiotherapist
or support worker is concerned about the support worker’s
competence. The physiotherapist will then need to decide
whether training is required. Users of physiotherapy serv­
ices have a right to expect those who deliver them to be
competent to do so. The physiotherapist has the
ultimate responsibility to the patient for ensuring this
is the case, but also needs to consider competence in the
context of effective resource use, in terms of both finance
and skills.
Newly qualified physiotherapists should recognise
and value the skills and knowledge that many support
Chapter 1
workers possess, particularly those who have extensive
experience within the profession, so that effective partner­
ships between physiotherapists and support workers can
contribute to the efficient and effective delivery of physio­
therapy services. Support workers, as associate members of
the CSP, are required to meet the expectations of the Code
in the same way physiotherapists are.
THE FUTURE
Ensuring safe and effective healthcare within the health
service continues to be a high priority for the government.
Change is constant and a key challenge for physiothera­
pists is to respond to the opportunities and risks presented
to ensure that high-quality services are delivered to
patients. The NHS White Paper (DH 2010a) sets out the
government’s long-term vision for the NHS. This builds
on the core values and principles of the NHS; that is, a
comprehensive service, available to all, free at the point of
use and based on need, not the ability to pay. The paper
sets out how the NHS will put patients at the heart of
everything the NHS does, be focussed on continuously
improving those things that really matter to patients (the
outcome of their healthcare) and empower and liberate
clinicians to innovate, with the freedom to focus on
improving healthcare services.
Many of the government’s priority health programmes
will be dependent for their success on the provision of
effective rehabilitation in order to ensure people can con­
tinue to lead independent lives, including services for
older people, children and people with long-term condi­
tions. Physiotherapists also have a key contribution to
make in keeping people fit for work through, for example,
the effective management of musculoskeletal problems or
the delivery of cardiac rehabilitation programmes. Ensur­
ing ergonomically safe environments in the workplace
and offering a rapid, work-based response when treatment
is needed provides another example of the value of the
profession.
Structural changes
Continued investment in healthcare will bring with it an
increase in the expectations of the public – whose money
is being used – and challenges from the government and
the public about the need to change and modernise the
way in which healthcare is delivered. One initiative is Any
Qualified Provider (The NHS Confederation 2011) which
aims to drive up quality, empower patients and enable
innovation. Management of musculoskeletal back pain
has been an area identified for patient choice in this way
and one which physiotherapists have a key role in deliver­
ing. While this may provide some opportunities for phys­
iotherapists, it may present a challenge to existing services.
17
 Tidy’s physiotherapy
It requires that services demonstrate their effectiveness,
are responsive to patients’ needs, are provided in settings
closer to patients’ own environments, are delivered more
speedily to maximise health benefits, and utilise available
resources more effectively.
More services delivered in primary
care and community settings
Physiotherapy already has a track record of delivering
responsive and effective services in primary care and
community settings. The success of domiciliary and
community-based physiotherapy services in avoiding
hospital admissions and allowing speedier discharges
will be further reinforced through intermediate care. Mus­
culoskeletal physiotherapy services delivered in GP prac­
tices and health centres, where trust is already established
between GPs and physiotherapists, has facilitated more
direct access to patients and more appropriate referrals,
either from GPs or through patients self-referring, making
services more efficient and effective.
The challenges for the future, however, will lie with
greater team working and delegation of tasks, with physio­
therapists being increasingly flexible, taking on teaching
or extended roles in order to allow other staff, such as
support workers, to deliver components of physiotherapy
services. There will be a need to take on some non-
physiotherapeutic roles, for example as a key worker or
case manager, in order to deliver a more consistent
approach to care for vulnerable people living in the
community.
Another challenge will be the experience of physio­
therapists working in isolation from their peers and,
with this, a greater emphasis needed to identify clear
access to peer support, supervision or shared CPD with
colleagues. Networking with colleagues with similar
interests and case mix at a local and national level will
become more important. Where face-to-face contact is
not possible, the use of electronic networks for commu­
nication and accessing learning resources will need to be
embraced. At a time when clinical governance, the
requirement for re-registration and the need for systems
to assure patients about practitioners’ competence and
safety are to the fore, physiotherapists will need to work
hard to create systems to support their ongoing learning,
while also ensuring their managers also accept their
responsibilities.
Delivering clinical and   current agendas through contacts with patient and public
cost-effective services
The profession can thrive only if it can clearly demonstrate
the ‘added value’ it offers to patients through increasing
their independence, shorter hospital stays, fewer work days
lost and so on. In order to achieve this, the profession
18
needs a two-pronged approach. Firstly, it needs to increase
its knowledge base about the effectiveness of specific inter­
ventions through research. Secondly, it needs to use infor­
mation from the evaluation of practice to demonstrate the
benefit to patients of those interventions. The profession
requires high-quality researchers who can access funding
in order to increase the knowledge base of the profession.
Challenges from commissioners of services to provide evi­
dence for the effectiveness of physiotherapy for particular
patient or diagnostic groups remain, and physio­therapy
services are in increasing jeopardy without it.
The profession must look critically at the outcomes of
interventions. Where research evidence shows that particu­
lar interventions are ineffective, these should stop being
provided. Where patient outcomes are used as a determin­
ant and demonstrate little or no effect, consideration
should be given to possible alternative strategies for
securing benefit to those patients, which may lie outside
physiotherapy. For physiotherapists to continue to provide
services in areas where there is little benefit weakens the
image of the profession to the public and to colleagues
from other professions. Where there is clear evidence for
a service or intervention, these should be explored and,
where possible, introduced.
There is a growing emphasis within the NHS and inde­
pendent providers on working smarter, looking at systems
of care from a patient’s perspective, breaking down what
are perceived as tribal boundaries between professions
and redesigning patient-centred delivery systems rather
than ‘doing things that way because we always have’. To
achieve this, physiotherapists have embraced new ways of
working, and this needs to continue. Opportunities will
emerge from redesign for physiotherapists to adopt new
and highly skilled roles in just the same way as the
successful creation of extended-scope practitioner and
physiotherapy consultant roles.
Influencing the agenda
To influence the healthcare agenda in the future, physio­
therapists need to be confident about their roles and be
able to articulate to others the value of physiotherapeutic
management and interventions or approaches from a
science-based, as well as a holistic point of view. Physio­
therapists must adopt a political astuteness that makes
them aware of the wider national and local drivers for
change in order that opportunities for the profession and
for services can be identified and seized positively. Physio­
therapists need to engage with, and be responsive to,
representatives, as well as senior managers and local
politicians.
The delivery of healthcare within organisations,
wheth­er state- or independently-funded, will continue to
be highly complex, ever-changing and resource-challenged.
Qualifying programmes are tasked with equipping
 The responsibilities of being a physiotherapist Chapter 1

physio­therapy students to deliver these services. Public
and private healthcare providers are looking for leaders
who are innovative, clear, lateral-thinkers and problem-
solvers. Physiotherapists are well placed to adopt such
roles and should be proactive in looking for opportunities
to do so. The skill is to turn challenges and pressures
into opportunities to demonstrate the ‘added value’ of
physio­therapy which, in turn, will provide job satisfac­
tion, and recognition and benefit for patients and the
profession.

SOURCES OF CRITICAL APPRAISAL TOOLS

Books and articles medical literature: II. How to use an Weblinks

Aveyard, H., Sharp, P., 2009. A
Beginner’s Guide to Evidence Based
Practice in Health and Social Care
Professions. Open University Press,
Maidenhead.
Burls, A., 2003. What is critical
appraisal? Haymarket Group Ltd,
http://www.whatisseries.co.uk/
whatis/pdfs/What_is_crit_appr.pdf,
accessed October 2012.
Crombie, I.K., 1996. The Pocket Guide
to Critical Appraisal. BMJ
Publishing, London.
DeBrun, C., Pearce-Smith, N., 2009.
Searching Skills Toolkit: Finding the
Evidence. Wiley-Blackwell, Oxford.
Greenhalgh, T., 2006. How to Read a
Paper: The Basis of Evidence-Based
Medicine, third ed. BMJ Publishing,
London.
Guyatt, G.H., Meade, M.O., Rennie, D.,
Cook, D.J., 2008. Users’ Guides
to the Medical Literature: Essentials
of Evidence Based Clinical Practice,
second ed. McGraw Hill, American
Medical Association, New York.
Guyatt, G.H., Sackett, D.L., Cook, D.J.,
et al., 1993. Users’ guides to the
article about therapy or prevention
A. Are the results of the study valid?
JAMA 270 (21), 2598–2601.
Guyatt, G.H., Sackett, D.L., Cook, D.J.,
et al., 1994. Users’ guides to the
medical literature: II. How to use an
article about therapy or prevention
B. What were the results and will
they help me in caring for my
patients? JAMA 271 (1), 59–63.
Herbert, R., Jamtvedt, G., Hagen, K.B.,
Mead, J., 2011. Practical
Evidence Based Physiotherapy,
second ed. Churchill Livingstone,
Edinburgh.
Jewell, D., 2009. Guide to Evidence-
Based Physical Therapist Practice,
second ed. Jones and Bartlett
Publishers, Sudbury, MA.
Oxman, A.D., Cook, D.J., Guyatt, G.H.,
1994. Users’ guides to the medical
literature: VI. How to use an
overview. JAMA 272 (17),
1367–1371.
Oxman, A.D., Sackett, D.L., Guyatt,
G.H., 1993. Users’ guides to the
medical literature: I. How to
get started. JAMA 270 (17),
2093–2095.
AGREE (Appraisal of Guidelines for
Research and Evaluation):
http://www.agreetrust.org/
CSP (Chartered Society of
Physiotherapy). CSP Critical
Appraisal Skills webpage. CSP
webpage explaining what critical
appraisal is and why you should do
it, and gives links to additional
sites: http://www.csp.org.uk/
professional-union/library/
bibliographic-databases/
critical-appraisal
SIGN 50 (Scottish Intercollegiate
Guidelines Network), 2008–2011.
A Guideline Developer’s Handbook.
A detailed description of SIGN’s
methodology, together with
examples of checklists, evidence
tables and considered judgement
forms, is given in the 50th
guideline, generally referred to as
SIGN 50: http://www.sign.ac.uk/
guidelines/fulltext/50/index.html
SPH (Solutions for Public Health).
Critical Appraisal Skills Programme:
http://www.sph.nhs.uk/what-we-do/
public-health-workforce/resources/
critical-appraisals-skills-programme

ACKNOWLEDGEMENTS

With thanks to Judy Mead who created the original chapter in the 13th edition; to Ralph Hammond and Gwyn Owen
for comments on drafts of this chapter; and to Claire Cox for comments on the final draft of this chapter.

19
 Tidy’s physiotherapy
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21
 Chapter
Collaborative health and social care, and
the role of interprofessional education
Alison Chambers, Lynn Clouder, Mandy Jones and Jill Wickham
INTRODUCTION
To new physiotherapy students it may seem strange to give
prominence to a chapter on interprofessional education
(IPE) and team working when they are already convinced
they want to be physiotherapists; why would they need to
know about other professions? It is well known that stu­
dents start their professional training with deeply ingrained
and historically informed views about what it means to be
a particular health and social care practitioner (Hean et al.
2006). However, the inclusion of this chapter, which is
new to this edition, signals a change in both professional
education and in practice that acknowledges that no one
profession can practise effectively in isolation and that a
change to a more collaborative way of working is necessary
to deliver the best outcomes for clients and service users.
In fact, we argue that all practice is collaborative.
Of course, students will find that IPE practices differ
with context and it is one of the aims of this chapter to
discuss the varied dimensions of IPE so that students
might develop critical awareness of their own programme
of study and the practice to which they are exposed during
clinical placement experience. We begin by clarifying what
we mean by IPE. One of the greatest challenges is the
conceptual ambiguity surrounding IPE and several related
terms that are used interchangeably and without discre­
tion. We will also explore the drivers and challenges that
will have influenced the IPE initiatives in which students
might find themselves involved.
It is important that students are aware from the outset
that IPE is not a taken for granted concept, accepted un­­
conditionally and embraced by all health and social care
professions, or even individuals with equal enthusiasm.
2 
There has been a long history of concern over poor com­
munication and professional rivalry between disciplines
and competing professionals (Cleake and Williamson
2007). Inevitably, this has influenced how health profes­
sional education has been delivered and, as a consequence,
it has been criticised for being ‘designed and delivered
within silos’ (Ramsammy 2010: 134). Research confirms
that silo models remain deeply entrenched in places
(Barker et al. 2005). We aim to introduce students to the
political, social and economic complexities of IPE that
have resulted in its patchy implementation. However, we
will also explore principles of best practice, different
models, the extent of its global spread and point to evi­
dence of impact where it exists.
Moving full circle in justifying the focus of the chapter,
we conclude by discussing the interface between pro­
fessional and interprofessional identities. Mhaolrunaigh
(2001) suggests that embracing the notion of working col­
laboratively requires students to reflect on their own pro­
fession and professional background, and to then see their
own profession in relation to ‘new others’. These are fun­
damental issues which might seem of a lower priority
than the more immediate concerns of proving compe­
tence and accumulating the vast knowledge base necessary
for contemporary practice. However, rather than com­
promising uni-professional knowledge, IPE provides the
means of adding to a different type of knowledge and
confers a different type of capability. Collaborative learn­
ing ‘allows students to become members of knowledge
communities whose common property is different from
the common property of the knowledge communities
they already belong to’ (Bruffee 1999: 3). IPE does not
detract from the status of the professional; it makes for a
flexible and open-minded practitioner capable of working
23
 Tidy’s physiotherapy
across boundaries and providing collaborative holistic
client care.
History of interprofessional
education (IPE)
IPE is simply defined as ‘Occasions when two or more
professionals learn with, from and about each other to
improve collaboration and the quality of care’ (CAIPE
1997). Although professionals may have shared their
learning experiences and expertise since formal healthcare
was conceptualised, specifically planned and structured
opportunities for IPE were not established in the UK until
the 1960s (Barr 2007), when the first interprofessional
symposium exploring ‘Family Health Care: The Team’ was
held in London (Kuenssberg 1967). In the UK, the evolu­
tion of IPE has been integrally linked with political change
and social growth.
Towards the end of the last century it became apparent
that many hospital- and community-based services were
essentially working in isolation, each with little knowledge
of the other’s role, expertise or skills. This absence of com­
munication and liaison between healthcare contributors
led to fragmented service delivery and substandard patient
care (Barr 2007). These collaborative failures sometimes
resulted in tragedy, particularly in child protection
(Colwell Report 1974; Laming Report, 2003) and psychi­
atric aftercare (DH 1994). The factors contributing to poor
working relationships between health and social care
professionals are extremely complex; many professions
had their roots entwined with status, class and gender
(Barr 2007), or provide identity to their members, promot­
ing prejudice or professional mistrust (Carpenter 1995).
Professional isolation was perpetuated through the use of
specialist language or jargon (Pietroni 1992), or keeping
individual patient records. Indeed, health and social care
students were not only entering their professional training
with established prejudice regarding other professions, but
qualifying and leaving with their prejudices reinforced
(McMichael and Gilloran 1984). This notion raised the
possibility of using education to improve interprofes­
sional understanding and successful collaborative working.
In 1987, the Centre for the Advancement of Interprofes­
sional Education (CAIPE) was established in the UK. Ini­
tially, this charity organisation directed its attention to
issues within primary care, but subsequently expanded
with interests in local government, higher education and
professional associations. The following year, the World
Health Organization (WHO) issued a statement which
highlighted the theory that if healthcare professionals
learned to collaborate as students, these skills would trans­
late to the workplace, facilitating effective clinical or pro­
fessional team working (WHO 1988). Indeed, throughout
the 1980s the Health Education Authority (HEA) launched
a series of shared learning workshops throughout England
and Wales, focussing on specific patient groups and their
24
problems (Spratley 1990). The concept of collaborative
learning was supported by the government white paper
‘Community Care in the next Decade and Beyond’ (DH
1989), which emphasised the importance of ‘multiprofes­
sional training’ and was used in the foundations of the
1990 NHS and Community Care Act (DH 1991). These
guidelines stated that ‘joint training’ was an expectation,
which must be included in community care plans and
training strategies (DH 1991; Barr 2007). The 2001
government white paper ‘Working Together, Learning
Together: A Framework for Lifelong Learning for the
NHS’ (DH 2001) provided a strategic framework and
co-ordinated approach to continued professional develop­
ment. It stated that ‘core skills, undertaken on a shared
basis with other professions, should be included from the
earliest stages in professional preparation in both theory
and practice settings’.
Most early IPE events were small-scale workshops or
short courses focussing on aspects of primary or commu­
nity care (Barr 2007). However, as many royal colleges,
professional and regulating bodies pledged support and
contributed to IPE evolution, educational initiatives grew
in size and commanded increasing interest. Over the last
30 years, IPE has become an established movement.
Shared learning between health and social care profession­
als is now embedded in most undergraduate curricula and
continually extends through professional development.
Governments continue to issue clear policy to encourage
collaborative practice and partnership working, to develop
students able to undertake, and contribute to, effective
NHS interprofessional working (Finch 2000).
Key points
IPE is defined as ‘Occasions when two or more
professionals learn with, from and about each other to
improve collaboration and the quality of care’.
The concept of IPE was born out of using education to
improve interprofessional understanding and successful
collaborative working to improve patient care.
The first specifically planned and structured opportunities
for IPE were held in the UK in 1966, when the first
interprofessional symposium exploring the ‘Family Health
Care: The Team’ was held in London.
In the UK, the evolution of IPE has been integrally linked
with political change and social growth.
Currently, IPE for both undergraduate and postgraduate
healthcare professionals is endorsed by the WHO, many
Royal Colleges and professional regulatory bodies.
Governments continue to issue clear policy to encourage
collaborative practice and partnership working, to
develop students able to undertake and contribute to
effective interprofessional working
 Collaborative health and social care, and the role of interprofessional education
Is IPE an international phenomenon?
The WHO identified IPE as a priority activity in 1984. In
1988, it published a report which drew on examples from
developed and developing countries to inform a unifying
definition and rationale for IPE (Barr 2009). The report
suggested that ‘students should learn together during
certain periods of their education to acquire the skills
necessary for solving the priority health problems of
individuals and communities known to be particularly
amendable to teamwork’ (Barr 2009: 17).
Since the late 1980s the call for a shift towards collabo­
rative interprofessional practices has crossed international
boundaries, inspired by a common goal of reducing health
inequalities and improving the health of populations.
These ideals were reiterated in the recent WHO Framework
for Interprofessional Education and Collaborative Care
(WHO 2010). WHO member states, eager to achieve equi­
table, fair, affordable and efficient care, are increasingly
focussing on primary care as providing the most suitable
means (Gilbert 2010). This focus is evident in the increase
in interest in interprofessional collaboration and in policy
commitments around the world, for example the Cana­
dian government’s call for a move towards patient-centred
interprofessional primary care (Health Canada 2003). In
Japan, where longevity rates are among the highest in the
world, IPE as a means of promoting collaborative working
is considered essential to promoting quality of life
(Takahashi and Sato 2009). Concerns about quality and
safety issues in the USA healthcare system has resulted in
resurgence in interest in IPE as a means of promoting
interprofessional collaboration and reducing patient
errors (Ragucci et al. 2009), while IPE in the UK has
emerged through a series of government policies aimed at
modernising health and social care.
A recent edition of the Journal of Interprofessional Care
(March 2010) drew attention to the development of IPE
internationally, highlighting that notwithstanding addi­
tional challenges and resource constraints in developing
countries, recognition of the benefits of a collaborative
workforce is not confined to Western countries. In 2009
the WHO established the Health Professionals Global
Network with the aim of maximising the potential of all
health professionals through a virtual network, fostering
interprofessional collaboration and contributing to the
global health agenda (see http://hpgn.org/). In 2010, the
network held a global consultation on IPE and collabora­
tion, and more than 1000 delegates from 97 countries
participated (Gilbert 2010). The recent Framework for
Action on Interprofessional Education and Collaborative
Practice (WHO 2010) captures a sense of IPE practices at
a global level. Representatives from 42 counties provided
insight into practices from practice, administration, educa­
tion and research perspectives.
The 42 countries contributing to the international scan
of IPE practices were: Armenia, Australia, Bahamas,
Chapter 2
Belgium, Canada, Cape Verde, Central African Republic,
China, Croatia, Denmark, Djibouti, Egypt, Germany,
Ghana, Greece, Guinea, India, Islamic Republic of Iran,
Iraq, Ireland, Japan, Jordan, Malaysia, Malta, Mexico,
Nepal, New Zealand, Norway, Pakistan, Papua New
Guinea, Poland, Portugal, Republic of Moldova, Saudi
Arabia, Singapore, South Africa, Sweden, Thailand, United
Arab Emirates, UK, USA and Uruguay.
The findings of the scan show that IPE occurs in ‘many
different countries and health care settings across a range
of income categories’ (according to the World Bank’s
Income Classification Scheme) and ‘involves students
from a broad range of disciplines including allied health,
medicine, midwifery, nursing and social work’ (WHO
2010: 16). Physiotherapy students in a wide range of coun­
tries can expect to find that IPE is a compulsory aspect of
their curriculum at undergraduate level that is mostly
delivered using a face-to-face approach, although the use of
technology to foster IPE is growing, especially where large
numbers of students from several professions are involved.
The aim of this section is to encourage you to examine
the concept of yourself as a practitioner as an integral
member of an interprofessional team by:
• considering the concept of IPE as integral to your
own learning;
• exploring how your own practice relates to the
concept of interprofessional working;
• reviewing how to anticipate and improve
interventions carried out by yourself and others;
• understanding the importance of current evidence
and policy, and how to take forward the learning
from a simulated environment into the workplace;
• developing the ability to interpret information by the
use of student-led interprofessional learning.
Having engaged with the learning you should have
developed the ability to explore current practice utilising
your reflective skills, knowledge and understanding to
improve your personal and professional development,
and thus enhance delivery of care to the service user in an
interprofessional working environment. A good practi­
tioner is, arguably, someone who is always punctual, who
is respectful to clients and to other team members, and is
considered to be reliable. What is the difference between
a good and an excellent practitioner? An excellent practi­
tioner is one who achieves best possible practice. While
working through this section you should be considering
what makes an excellent practitioner and at the same time
reflecting upon your own practice to identify ways to
always strive for excellence. There are certain factors that
make being a practitioner easier. Physiotherapy students
need to develop skills to enable them to work in an inter­
professional environment. As well as the interpersonal
skills required to work effectively in a range of environ­
ments with a range of personnel (at all levels), there is a
need to develop confidence, clinical reasoning, evaluation
25
 Tidy’s physiotherapy

and reflective skills (Smith and Green 2003). In fulfilling economic and technical drivers that underpin the require­
the ability to self reflect it is imperative to understand ment for IPE (Table 2.2).
therapeutic use of self, self-awareness and constructive use The imperative to expose pre-registration health and
of feedback. Exploration of these skills will make the social care students to IPE has, for some time, been di­­
application of interprofessional working more feasible. rected by a number of policy directives and is not new (DH
2000a, 2000b, 2001, 2009, 2010a, 2010b; Hammick et al.
2002). Since the NHS plan was published in 2000, there
THE IPE CONTEXT WITHIN THE UK has been an increased emphasis on a patient-led NHS and,
alongside that, the requirement for IPE to be an integral
part of education and training programmes. UK health
When exploring the literature concerned with IPE, it is
professional regulatory bodies also demand the inclusion
evident that there is some confusion over descriptions and
of IPE in all professional curricula (NMC 2004; HCPC
definitions. The nomenclature can be confusing, as Barr
2004). Within higher education, the quality assurance of
(2005: xvii) states: ‘interprofessional education is bedevil­
health and social care education has as a central tenet the
led by terminological inexactitude’. For the purposes of
requirement to demonstrate where and how IPE is being
this chapter, the authors have used the CAIPE (1997) defi­
taught within pre-registration curricula (QAA 2006).
nition of IPE, emphasising learning from, with and about
Recent policy documents (DH 2000a, 2000b, 2001,
each other.
2006, 2009, 2010a, 2010b) re-emphasise the continuing
Table 2.1 describes the nomenclature you may find in
drive towards an agenda of modernisation and
the literature and/or experience as part of your learning
experiences.
Table 2.2  IPE context analysis
As described in the previous sections, there is no defini­
tive model of IPE; thus, organisations have developed their
own models which best suit their organisational contexts Political Economic
and student mix. The Leicester Model of IPE is one example Government policy – NHS Cost improvement
(Lennox and Anderson 2007); for further examples you plan, quality, choice, – efficient use of limited
are directed to the higher Education Academy occasional right care, right place, resources
paper Piloting Interprofessional Education (Barr 2007). right professional, equity Value for money – best
As physiotherapy students it can sometimes be difficult and excellence liberating care, best time, best
to understand the reasoning behind the inclusion of IPE the NHS, modernisation place
in your uni-professional programme. The previous sec­ and improvement Increased cost of
tions have provided you with an overview of the history Professional bodies – healthcare – change in
behind the development of IPE, as well as some examples curriculum frameworks, demographics
of how you may experience IPE during your studies. This codes of conduct, scope
next section will describe the context in which IPE exists of practice, continuing
and thus enable you to understand its importance to you professional development
as an individual, and to the wider health and social care requirements
professional community. Professional regulation –
Irrespective of how different organisations have imple­ standards and
mented IPE they share a common context in which they proficiencies,
accountability
operate; this section will outline the political, social,
Healthcare organisations –
ways of working, service
design, workforce design
Table 2.1  IPE common terms
Social Technological
Term Learning
Public and patient Treatment advances – living
Multi-professional Learn side-by-side empowerment – patient- longer
centred health and social Improved diagnostics
Interprofessional Learn with, from and care – earlier diagnosis
about each other Expert patient New service delivery
Change in demographics models, e.g.
Shared learning Learn alongside each other – ageing population, telemedicine
with NO interaction long-term conditions Enhanced information
Common learning Learning a common Increased professional technology
curriculum accountability – in
response to failures
Source: Barr (2005). in care delivery

26
 Collaborative health and social care, and the role of interprofessional education
improvement in health and social care services, predicated
upon the view that interprofessional working is key to its
success. Also, the political imperative to ensure continual
service improvement cannot be achieved without profes­
sionals working together: ‘if we are to achieve the aim of
health care teams continuously improving the quality of
care they provide to their patients, we need to deepen
our understanding of what is needed to enable them to
work and learn together’ (Wilcock et al. 2009: 88). As
Davidoff and Batalden (2005: 80) suggest, ‘the ideal con­
ditions for achieving this are when everyone working in
health care recognises that they have two jobs when they
come to work every day, to do their work and improve it’.
In addition, the National Institute for Health and Clinical
Excellence (NICE) supports the notion of creating a more
flexible workforce that can operate across boundaries and
promote partnerships (www.nice.org.uk).
Failures in traditional care delivery have contributed
to the call for greater collaboration of healthcare profes­
sionals. Examples such as the Bristol Royal Infirmary
Inquiry (DH 2001), the Victoria Climbie Inquiry (Laming
Report 2003) and, more recently, Baby P (Laming 2008)
highlight the fact that uni-professional working may
hinder optimum care while interprofessional working
may help to avoid these failures. These very public failures
have led to an increased scrutiny of health and social care
professionals, with increased accountability.
The demographic changes in the UK population – an
increasingly ageing population and people living with
long-term conditions as a result of improvements in diag­
nosis and treatment advances – has led for a call for
healthcare professionals to work across traditional bound­
aries and create inter-agency partnerships, all requiring
improved collaboration between professional groups
(Wanless 2004).
The importance of IPE had sufficient prominence to
lead, in 2001, to the Department of Health (DH) commis­
sioning four, leading-edge IPE pilot programmes. These
were collaborations between universities and the then
Workforce Development Confederations (a body respon­
sible for the commissioning of health and social care
education on behalf of the DH via Strategic Health
Authorities on a regional basis).
Within the Allied Health Professions (AHP) the publica­
tion in 2000 of the ‘Meeting the Challenge: A Strategy
for Allied Health Professions’ document further empha­
sised the importance of collaboration and cross-boundary
working outside of traditional uni-professional silos.
Although primarily concerned with describing the changes
in the roles of AHP within contemporary healthcare, one
of the strategy’s main tenets called for undergraduate
education programmes to be more flexible and more
patient- and practice-centred via the inclusion of enhanced
opportunities for IPE (DH 2000a, 2000b).
In 2005, the Health and Care Professions Council
(HCPC 2012) standards of proficiency under the section
relating to professional relationships states that:
Chapter 2
Registrants need to understand the need to build
and sustain professional relationships
Are able to contribute effectively as a member of
a multidisciplinary team
Are able to sustain professional relationships as
an independent practitioner
In 2006 the Quality Assurance Agency (QAA) produced
generic benchmarking across all health and social care
programmes by including common statements while at
the same time safeguarding the distinctive learning needs
of each profession. These benchmarks include reference to
integrated service delivery.
Despite all these initiatives around increasing the
opportunity for IPE for health and social care students in
practice, there is still a lack of substantive evidence that
engaging in IPE impacts positively on interprofessional
working in practice. In response to this, the Creating
an Interprofessional Workforce (CIPW) project was
initiated and findings were published in 2007. CIPW
provides a strategic framework for IPE and training
to underpin collaborative working practices and partner­
ships (DH 2006).
In 2008, the NHS next stage review led by Lord Darzi
further emphasised an NHS founded upon providing high
quality care for all through a patient-led NHS.
Most recently, the new government published its NHS
white paper ‘Equity and Excellence: Liberating the NHS’
(DH 2010a). Although in many ways this strategy moves
away from the previous government’s strategy for the NHS,
the imperative for a patient-centred NHS remains a key
priority. The main tenets of this white paper are:
• patients and public first;
• services designed around patient’s individual needs,
lifestyles and aspirations;
• giving citizens a greater say in how the NHS is run;
• a truly patient-led NHS;
• strengthening the collective voice of patients by
creating Health Watch England;
• shared decision-making – ‘no decision about me
without me’;
• focussed upon outcomes and quality standards.
In 2011, contemporary health and social care is increas­
ingly complex, requiring integrated organisations which
require a work force that is adaptable, creative and col­
laborative. IPE provides the foundations on which to
develop graduates who are capable of building strong
interprofessional relationships in practice in order to
engage in collaborative working.
Over the past 10 years, the modernisation of the NHS
has seen a significant cultural shift in the way that health­
care is delivered, requiring healthcare professionals to
work in very different ways. Prior to the modernisation
movement, healthcare was essentially profession-led,
where professionals made decisions about patients for
patients. The shift away from profession-focussed care to
27
 Tidy’s physiotherapy
one where patients and the public are empowered to make
decisions and choices in relation to their healthcare has
required professionals to work in different ways. No longer
is it acceptable for professionals to exist in professional
silos. Service modernisation has resulted in service deliv­
ery models that are predicated upon care pathways and
not profession focussed pathways. Practitioners increas­
ingly work in multi-professional teams associated with a
specific care pathway (e.g. long-term conditions, stroke,
cancer, end of life, musculoskeletal) as described in the
National Service Frameworks (DH 2006).
The list below provides a checklist of the publications
that outline the major drivers:
World Health Organization (WHO)
1988 Learning Together to Work Together for Health
2010 WHO Framework for Action on Interprofessional
Education and Collaborative Practice
Department of Health (DH)
2000 A Health Service of All the Talents: Developing the
NHS workforce
2000 The NHS Plan: A plan for investment, A plan for
reform
2000 Meeting the Challenge: A strategy for the Allied
Health Professions
2001 Working together, learning together
2003 The Victoria Climbie Inquiry: Report of an inquiry
by Lord Laming
2004 The NHS Knowledge and Skills Framework and the
Development Review Process
2006 Our Health, Our Care, Our Say
2007 Creating an Interprofessional Workforce
2008 Allied Health Professions Competence Framework
2008 High Quality Care for All: NHS Next Stage Review
2010 Equity and Excellence: Liberating the NHS
2010 Equity and Excellence: Developing the NHS
workforce
2010 Equity and Excellence: Public Health Paper
Professional, Regulatory and Statutory Bodies
2006 QAA benchmark statements
2006 HCPC standards of proficiency
2010 CSP curriculum framework
It is these documents that provide the policy context
and major driving force behind the impetus for the inclu­
sion of IPE in the education and training of all health and
social care professionals. Contemporary health and social
care service delivery models require a workforce capable
of working together in the interests of improving health­
care outcomes focussed upon the patient’s needs and not
the profession’s.
All health and social care professionals are required to
work in interprofessional teams within integrated service
delivery models across and around professional bounda­
ries. All health and social care students are required to be
interprofessionally competent (at the very least capable of
28
working collaboratively) – actively engaging in IPE as an
integral part of their professional programmes supports
the development of such competence.
IPE provides the vehicle for students to:
• gain an understanding of the complexity of
interprofessional health and social care delivery;
• develop and practise team-working skills
(communication, negotiation, value, respect,
collective decision-making, joint goal-setting and
outcome measurement);
• be prepared for working across traditional boundaries;
• practise their own professional role within the
context of the wider healthcare team in a secure
learning context where mistakes will not have real
life consequences;
• test out and reflect upon their own professional
knowledge, skills and values against others;
• test out negotiating skills around professional
boundaries and learn about/from the difficulties
inherent in the process.
It can be argued that one of the most important lessons
for you as undergraduates to take away from your experi­
ences of IPE is the recognition that no one individual
professional or distinct professional group can meet all the
health and social needs of individuals requiring health
and social care intervention. In order to contribute to the
improvement of health outcomes for their patients, today’s
practitioners must be able and willing to work collabora­
tively, knowing when they have a contribution to make
and, importantly, when they do not and therefore seek
help from colleagues. IPE provides real opportunities for
undergraduates and postgraduates to learn with and from
each other in ways that uni-professional learning will
never be able to do (Bokhour 2006; Lennox and Anderson
2007; Barr 2007).
Learning together is never easy; students studying
specific professional programmes commence those pro­
grammes with well-formed constructions of the profes­
sional they are learning to become. This can make learning
together a difficult process. It is never easy when cultures
collide (Jenkins 2004). IPE can provide an opportunity to
improve understanding of self; Chambers (2009) suggests
that during interprofessional exchanges students test out
their emerging professional identity as a way of working
out what they are not in order to work out what they are.
She suggests that IPE is pivotal in the process of construct­
ing a particular professional identity.
IPE and collaborative working
A number of significant political and societal and profes­
sional changes have taken place over the past ten years
and continue to do so. These influence how health and
social students are prepared for a career likely to span 40
years. The changes as described above have had a major
influence on the education and training of healthcare
 Collaborative health and social care, and the role of interprofessional education Chapter 2

professionals as educators are charged with ensuring

health and social care graduates are equipped to be effec­ Key points for successful collaborative
tive practitioners in a complex, ever-evolving health and working
social care system. Educators are required to prepare grad­
uates who are fit for practice and fit for award. The patient • Successful • Individuals’ requirements
and public empowerment agenda continues to be a prior­ team-working
ity. In order to attend to this, healthcare professionals will
• Openness • Being secure within own
need to practise in ways that empower patients to be part­ professional role but not
ners in their own care (DH 2009). defensive
For this to be successful, professionals will need to prac­ • A willingness to see things
tise collaboratively, work in partnership with other from all sides
members of the health and social care team, engage in
joint decision-making and goal-setting, and ultimately • Value and • Understanding of other
work towards the same end. Interprofessional learning can respect different professionals’ expertise and
support the development of skills enabling graduates to perspectives contribution
be fit for purpose. • Appreciation of different
perspectives
Collaborative working requires individuals to be good
• Being able to see things from
at team-working, be aware of their own contribution and
a different perspective
the contribution of others, be willing to take a back seat
as and when this is in the best interest of the patient, and • Shared • Negotiated outcomes that
work towards agreed outcomes and goals with the patient outcomes, matter to the patient not
at the centre of any decision-making. improved health individual professionals
Remember … … ‘No decision about me without me’ outcomes for • Patients as partners
(DH 2009). patients • Shared intelligence

• Agreed roles • Agreeing professional

INTERPROFESSIONAL EDUCATION
(IPE) IN PRACTICE
Although the primary motivation behind the evolution
and instigation of IPE was to improve health and
social care service delivery, the rationale for IPE has
firm roots in adult educational theory (www.faculty.
londondeanery.ac.uk). In particular, early work by Allport
(1954) generated the term ’contact hypothesis’. This theory
is often applied to IPE (Street et al. 2007) and ‘suggests
that attitudes towards diverse groups will improve with
contact with that group’, particularly where ‘there is equal
status, focus on differences as well as similarities, the per­
ception that members are “typical” of their professional
group, and opportunity to experience successful working
together’. Freeth (in Hammick et al. 2007) also believes
that positive interprofessional contact may change atti­
tudes and that well-facilitated IPE can channel conflict and
stimulate critical debate which promotes professional and
personal development. Jarvis (1983) proposed that adults
learn effectively when faced with a discrepancy between
what they believe they know and what they actually need
to know. This draws an interesting parallel with attitudes
of established professional stereotyping and the need for
collaborative working. Coulshed (1993) stressed the
importance of ownership of learning, highlighting that
effective adult learning takes place when students can
work collaboratively in groups, drawing and reflecting
and boundaries, the most
responsibilities appropriate professional
providing the right intervention
• Active • Recognising own professional
engagement contributions and limitations
• Flexible • Willingness to revise own role
and priorities for improved
patient outcome when
required
• May involve picking up actions/
tasks and giving tasks away to
other team members
on previous experiences to solve specific problems,
thus controlling their work. Indeed, it is suggested that
an understanding of adult learning concepts is key
for positively received IPE, to ensure learning needs are
met through well-structured curriculum development
(Hammick et al. 2007). Miler et al. (1999) advocate the
use of an in­­teractive approach, such as ‘user-centred’ sce­
narios to IPE, to enable students to effectively transfer
their collaborative knowledge and skills directly to the
healthcare environment.
Over the last 10 years many IPE initiatives have been
launched over a wide variety of healthcare settings
(Carpenter and Hewstone 1996; Barnes et al. 2000; Gilbert
et al. 2000; McNair et al. 2001; Way et al. 2002; Barrett
et al. 2003; Kilminster et al. 2004; Street et al. 2007),

29
 Tidy’s physiotherapy
providing a framework for successful implementation. The
optimal time to commence IPE has induced much debate,
but as negative professional stereotyping may evolve
early in training, Vanclay (1997) advocates that IPE
should be implemented from the beginning of profes­
sional education – a view endorsed by the WHO (1988).
Carpenter and Hewstone (1996) evaluated a compulsory
week-long, shared learning programme for doctors and
social workers, where students were given opportunities
to ‘undertake successful joint work in a co-operative
atmosphere’. Working in pairs, they planned the manage­
ment of a clinical case from their own professional stand­
point, co-facilitated by both a doctor and social worker,
who focussed their attention and positive feedback on
differences and any similarities between their approaches.
Prior to starting the programme, the Professor of Mental
Health demonstrated institutional support to the medical
students and each group was given an overview of the
educational background of the other. Although not
without difficulty, upon completion both sets of students
positively evaluated the programme, gaining an improved
attitude toward the other profession. Each rated the other
as professionally competent and reported increased
knowledge of their skills, role and duties, together with a
heightened awareness of what is required for effective col­
laborative working.
The role of the educator has been highlighted as key to
the success of IPE initiatives (Ponzer et al. 2004; Freeth
et al. 2005; Buring et al. 2009). Uniting educators from
differing backgrounds to teach together is not sufficient to
provide a beneficial IPE experience (Buring et al. 2009).
Buring et al. believe that IPE educators need to develop
and nurture their approach through their own learning
in order to educate reflective practitioners who can
work collaboratively within the interprofessional health­
care team. Shared knowledge, skills and values are
imperative for educators within the collaborative setting
(Buring et al. 2009). In addition, through the process of
self-development, as IPE educators evolve, implement and
teach together, not only do they gain each other’s profes­
sional trust and understanding, but they also provide a
positive role model for the students they educate
(Freeth et al. 2005). The importance of staff development
and its impact on effective IPE was highlighted in a
recent systematic review of interprofessional education
(Hammick et al. 2007). However, for this process to work,
it requires institutional support which challenges the his­
torical hierarchy among healthcare professionals (Buring
et al. 2009). Indeed, management support and other
resources, such as time, appear to be of paramount im­­
portance in founding and maintaining IPE initiatives
(Hammick et al. 2007). Evaluation of a two-day interpro­
fessional team-building workshop attended by 21 students
from 13 undergraduate health and human service pro­
grammes in Canada concluded that to successfully imple­
ment an IPE programme, a university structure which
30
actively fosters collaboration across its own departments
is essential (Gilbert et al. 2000).
Interprofessional learning is centred upon an exchange
of professional knowledge, understanding, attitudes or
skills to improve collaboration and, ultimately, healthcare
outcomes (www.faculty.londondeanery.ac.uk). Therefore,
delivery of each IPE initiative must be customised and
tailored to reflect particular service delivery settings, to
provide a positive experience for its targeted practitioners
(Kilminster et al. 2004; Hammick et al. 2007). It is much
more meaningful to learn interprofessional behaviour in
the context of current or future practice, than in an artifi­
cial simulated situation (Kilminster et al. 2004; Hammick
et al. 2007). Furthermore, the design of the IPE initiative
and the timing of its delivery must be appropriate to
match the stage of professional development of its partici­
pants (Kilminster et al. 2004).
Co-operation and collaboration have been identified as
the key features of IPE (Walker et al. 1998; Way et al.
2000). Way et al. believe collaboration is a pro­cess for
interprofessional communication and decision-making,
allowing the knowledge, skills and views of different
healthcare professionals to unite and provide holistic
patient care. Following the development and evaluation
of a series of case studies aimed at collaboration between
primary care partners, this group identified seven elements
which they deem to be essential for successful collab­
orative practice: responsibility and accountability, co-­
ordination, communication, co-operation, assertiveness,
autonomy, and mutual trust and respect (Way et al. 2002).
This view was supported by Kilminster et al. (2004)
who implemented patient-focussed workshops involving
pre-registration house officers, student nurses and pre-
registration pharmacists. Evaluation of this initiative
included the curriculum development, delivery of the
workshops and how each influenced the participants.
They concluded that the workshops were successful, with
participants gaining increased respect for each other’s pro­
fession. This mutual respect enabled each professional
group to feel comfortable with the other to offer and ask
for advice. In addition, all professional groups reported
enhanced communications skills, both between different
team members and with the patient. Similar findings were
described by Street et al. (2007), who evaluated a paediat­
ric community practice-based IPE initiative involving
medical and paediatric nursing students. These workers
highlighted the enhanced learning opportunities gener­
ated through interprofessional collaboration, together
with a change in attitude between the professions; profes­
sional stereotyping was reduced, while understanding of
specific roles, knowledge and skills increased.
Healthcare professionals do not work in isolation, but
as a contributor to the multi-professional team. The
diverse and complex nature of the clinical environment
demands effective collaborative working. As such, IPE
provides an opportunity for healthcare professionals to
 Collaborative health and social care, and the role of interprofessional education
develop the essential skills they require to improve patient
outcomes, enhance service delivery and become reflective,
collaborative practitioners. However, despite a growing
evidence base, the implementation of IPE initiatives
remains a challenge. Further robust evaluation of IPE ini­
tiatives is required to measure its effect on interprofes­
sional collaboration.
Without trust and respect, co-operation cannot
exist. Assertiveness becomes threatening,
responsibility is avoided, communication is
hampered, autonomy is suppressed and
co-operation is haphazard…
(Norsen et al. 1995)
Key points
• The rationale for IPE has firm roots in adult
educational theory.
• An understanding of adult learning concepts is key for
positively received IPE, to ensure learning needs are
met through well-structured curriculum development.
• Positive interprofessional contact may change
attitudes, may channel conflict and stimulate critical
debate, which promotes professional and personal
development.
• The optimal time to start IPE continues to induce
much debate, but as negative professional
stereotyping may evolve early in training IPE should
ideally be implemented from the beginning of
professional education.
• The role of the educator has been highlighted as key
to the success of IPE initiatives.
• IPE educators need to develop and nurture their
approach through their own learning in order to
educate reflective practitioners who can work
collaboratively within the interprofessional healthcare
team.
• Institutional and management support, and other
resources, such as time, appear to be of paramount
importance in founding and maintaining IPE initiatives.
• Delivery of any IPE initiative must be customised and
tailored to reflect particular service delivery settings,
to provide a positive experience for its targeted
practitioners.
• Furthermore, the design of the IPE initiative and the
timing of its delivery must be appropriate to match the
stage of professional development of its participants.
• Key elements deemed essential for successful
collaborative practice are: responsibility and
accountability; co-ordination; communication;
co-operation; assertiveness; autonomy; and mutual
trust and respect.
Chapter 2
IPE and technology
Although sceptics question whether it is feasible to learn
with, from and about each other through the use of tech­
nology, it has become an important means of interaction
and communication in the fast-paced world of health and
social care practice. For this reason technology-enhanced
IPE is highly relevant and its use is increasing. The poten­
tial for e-learning IPE approaches to effectively prepare
students for collaborative practice is being endorsed
(Hughes et al. 2004; Posey and Pintz 2006), although
its use is still being developed, refined and tested (Barr
2010). In some instances, where staff are less confident in
the use of technology or unconvinced that it will be
effective, technology-enhanced IPE is being developed
alongside conventional methods of teaching (Williams
and Lakhani 2010).
Initiatives utilising technology have generally done so
to overcome the challenge of bringing together large
groups of students from geographically dispersed loca­
tions. These initiatives often involve a blended learning
approach where face-to-face interaction is combined with
online activities (see, for instance, Atack et al. 2009).
Other IPE programmes, such as the joint Coventry Univer­
sity and Warwick Medical School Interprofessional Learn­
ing Pathway (IPLP), occur exclusively online (Bluteau and
Jackson 2009) accommodating over 1200 students simul­
taneously. The IPLP is built around learning resources or
learning objects, one of which is known as ‘the street’,
which contains a number of families that provide the
focus for online interprofessional collaboration. The
Wessex Bay web-based simulated community operates in
much the same way in promoting active student engage­
ment in case analysis, discussion, debate, collaborative
problem-solving and decision-making (Hutchings et al.
2010). Such resources generally act as triggers for synchro­
nous or asynchronous discussion using discussion forums,
boards or chat rooms, or Web 2.0 applications, such as
blogs and wikis. These tools allow interaction, including
varying degrees of social exchange, as well as the testing
and exchange of ideas, probing of assumptions, position
taking, the expression of different perspectives, informal
argumentation and collaborative sense-making – all of
which contribute towards critical discourse. One of the
advantages of the online approach to IPE is that it provides
a safe space in which to test out ideas. While students can
be apprehensive about online learning and doubt their
information technology skills (Miers et al. 2007), it pro­
vides ‘anywhere anytime learning’ that is attractive to busy
students (MacNeill et al. 2010).
The section will help you to work out strategies to start
and enhance your skills as a practitioner integral to the
team situation. It will give you some practical guidance;
it will not make being a practitioner any easier (the more
we learn the more we worry we are inadequate), but it
might help!
31
 Tidy’s physiotherapy
Practice-based learning
Collaboration in the workplace and in the higher educa­
tion system is not a choice but a directive. In 2000 the DH
(DH 2000a) published a review of workforce planning
stating that an unhelpful lack of flexibility in the then
current ways of working was not helped by working
and educational systems that did not encourage multi-
disciplinary practices. A following document, ‘The NHS
Plan’ (DH 2000b), offered a commitment to interprofes­
sional working. In reviewing its workforce planning
the DH produced ‘The Knowledge and Skills Framework’
(DH 2004), which reviewed workforce planning and out­
lined the qualities of all health professionals working in
the NHS to incorporate a requirement for interprofes­
sional working. The key areas set out in these documents
remain current and underpin educational philosophy
associated with interdisciplinary working. A summary of
these can be seen in Table 2.3.
Simulated learning
Simulated learning opportunities are becoming increas­
ingly utilised in both undergraduate and postgraduate
teaching environments. Simulated learning may be based
in a skills laboratory with equipment and dummy models,
or may be web-based. Learning within simulated practice
environments facilitates opportunities to enhance profes­
sional practice and to increase students’ confidence when
in the real clinical setting. In a study based on a simulated
ward setting Ker et al. (2003) reported that students
Table 2.3  Key policy drivers for interprofessional
working [adapted from NHS plan (DH 2000b)]
All NHS staff must have a curriculum (undergraduate and
postgraduate) to enable them to have skills and
knowledge to respond effectively to the individual needs
of patients
Joint training should occur across professions in
communication skills and in NHS principles and
organisation
All health professionals should expect their education and
training to include common learning with other
professions
Common learning should take place in practice
placements, as well as in the classroom
Common learning should centre on the needs of patients
Multi-skilled teams and networks will be based primarily
in communities but supported by, and include, people
working in hospitals
Leadership and in working in multi-disciplinary settings a
focus of education and training programmes
32
gained valuable experience in collaborative team-working,
effective leadership, the ability to prioritise workloads and
competence in clinical performance. Simulated learning
usually involves students working with a facilitator who
will be able to guide the student to utilise the learning in
a real practice. Students need to be committed to the
experience and provide evidence to support the learning
achieved. This evidence might be literature related to the
underpinning evidence base or evidence to show compe­
tencies have been gained in clinical skills. When working
with students from other professions the group should be
jointly responsible for providing documentation to sum­
marise the learning on the simulated practice. While on
clinical practice, students can share learning from simu­
lated practice with their clinical educator, encouraging the
link between theory and practice.
In resource-heavy times where there may be difficulties
in accessing clinical hours, simulated learning may seem
like a panacea and while the pedagogy has undoubtedly
much to recommend, caution must also be exerted.
Kneebone (2005) emphasises that simulations should not
be accepted without critique and that caution should be
taken to ensure that emphasis does not focus on the tech­
nology alone without thorough regard for the underpin­
ning evidence. He identifies four key areas for simulated
learning: gaining technical proficiency; the place of expert
assistance; learning within a professional context; and the
affective component of learning that is the effect of an
emotive component. He proposes that simulations present
opportunity to practise within a safe environment; facili­
tating consolidation of skills, they should be supported by
a tutor with tutor support being reduced as the student
becomes more adept. If these premises are followed then
simulated learning can offer a link to real-life clinical
experience, providing a supportive, motivational and
learner-centred environment that will ultimately benefit
the service user.
Problem-based learning
Higher education institutes in the UK utilise a range of
different pedagogical methods. Problem-based learning
(PBL) is a style used in whole, or in part, on many physi­
otherapy programmes, regardless of whether or not this
is the type of learning experience practised by your edu­
cators. A consideration of the approach can be helpful
for you as a student as the concept transfers readily into
the clinical practice setting. PBL was first developed three
decades ago by Barrows and Tamblyn at McMaster Uni­
versity during the 1980s (Major and Palmer 2001: 2).
The purpose of this type of learning was to encourage
students to be able to respond to real-life clinical situa­
tions by drawing upon transferrable knowledge and
skills, thus maximising the ability to respond appropri­
ately to the specific needs of a particular individual while
responding to the needs of the current context, such as
resource constraints or other professionals’ skills mix.
 Collaborative health and social care, and the role of interprofessional education
Savin-Baden (2000: 5–6) states that PBL depends on
students acknowledging responsibility for learning –
drawing from experience while intertwining theory and
practice. The focus is on processes rather than knowledge
acquisition gained through communication and interper­
sonal skills.
What does PBL mean to the learner? It offers you,
the student, the opportunity to critically analyse a situa­
tion that might be based on a case study or a scenario,
and, in particular, to engage in this learning with others
from different professions. Thus, as well as coming to a
conclusion on what you might do, you will also be intro­
duced to the multi-dimensional aspect of what others
might do; together you will devise a much more informed
approach. According to Thompson (2010), there is evi­
dence to suggest that PBL in an interprofessional setting
encourages improved attitudes towards other profession­
als, which she suggests will lead to improved care of
the service user as central to the practice of all health
professionals.
Student-led interprofessional
learning
There are many ways in which students can become proac­
tive interprofessional learners, be it in the clinical or in the
university setting. Contemporary methods of communica­
tion mean that it has never been easier to form a network
of fellow learners. Online networks can offer a stimulating
and safe environment for the development of a range of
professional skills. In order for students to lead in a learn­
ing context it is important to understand that:
• there is always more than one way to deal with a
situation;
• no two people will react in exactly the same way to a
given situation;
• the way that you react to an incident really matters;
• by reflecting on interprofessional learning incidents
you will be better able to cope with similar episodes
in the future;
• a positive attitude and self-esteem will enable you to
strive for excellence;
• whatever other factors are present, the service user
must always be the most important entity.
In student-led interprofessional learning the mentor
does not need to be a tutor or health professional –
another student may take on this role. A study by
Clouder et al. (2010) suggested that student learning is
optimised by peer mentoring. They found that where
students across a range of disciplines engaged in web-
based interprofessional online discussion forums the role
of mentor was valued by other students who, at times,
found the student added value compared with a profes­
sional mentor. A student mentor can offer empathy and
awareness of contemporary issues affecting other students,
Chapter 2
for example, of which a tutor may not have the same
insight.
It is important for interprofessional learning to be max­
imised so that students engage; sometimes there is a reluc­
tance to join in this type of forum. To see the value of this
experience join an existing scheme or start your own.
Reflect on the benefits that you gain from the experience
and feed these back to others. People influence one
another – the way that we act as an individual may be very
different to the ways in which we act when part of a group.
In order to strive to be able to perform in a way that fits
both our own values and those of the profession it is
useful to gain understanding in the ways in which we and
others might be influenced in the group setting of an
interprofessional team – the more who engage the better
the experience will be!
PROFESSIONAL IDENTITY AND
INTERPROFESSIONALISM
Wackerhausen (2009) considers professional identity at
macro- and micro-levels. The macro-level is the public
face of the profession formed through the profession’s
official recognition; in other words, its regulations, privi­
leges and duties, public perceptions, related professions’
views, and the self image promoted by the profession’s
leaders and ideologists. Macro professional identity is con­
tinually changing as identity is negotiated. Professions
collaborate out of necessity, but also compete with one
another and have goals that Wackerhausen argues do not
promote genuine collaboration.
Micro-level professional identity is dependent on
exhibiting the qualities that a person needs to exhibit to
be a fully acknowledged member of the profession, as
well as the behaviour consistent with the profession’s
‘cultural dimensions’. He refers to ‘a way of speaking, a
way of questioning, a way of understanding and explain­
ing, a way of seeing and valuing, a way of telling narra­
tives’ and the obligation of the student to become ‘one
of our kind’ (Wackerhausen 2009: 461). Wackerhausen
argues that professional identity hampers interprofes­
sional collaboration at both levels. At the micro-level
habitual ways of talking, perceiving, valuing, doing
and assuming conflict with other professions while, at
the macro-level, boundaries and barriers are reinforced
by negative narratives and competition. This rather
depressing outlook is that ‘self complacent, know-all
practitioners and professionals see interprofessional col­
laboration more as an (un)avoidable evil than a desirable
necessity’ (Wackerhausen 2009).
Is it inevitable that professional identity impacts nega­
tively on IPE and interprofessional working? We believe
not. As students are socialised into a profession they are
gradually shaped to take on a professional identity
33
 Tidy’s physiotherapy
associated with that profession, becoming a nurse, a medic
or a physiotherapist. Socialisation is ‘the process by which
people selectively acquire the values and attitudes, the
interests, skills and knowledge – in short – the culture
current in groups in which they are, or seek to become, a
member’ (Merton et al. 1957: 278). The process has been
described as ‘indoctrination’ (Sparkes, 2002) and certainly
involves elements of ‘internalization’ (Hayden 1995) of
professional norms.
Inevitably, different training and philosophical ap­­
proaches have resulted in the professions evolving
separately (Fitzsimmons and White 1997) and in the pro­
fessions being described as ‘warring tribes’ (Becher and
Trowler 2001). The sense of shared identity that develops
in groups promotes what William Sumner identified in
1906 as ‘in-group’ and ‘out-group’ dynamics (Brewer
1979). Social identity theory explains how such dynamics
effect intergroup relations; people seek for their in-group
a positive distinctiveness from out-groups; in other words,
they distinguish between ‘us’ and ‘them’ (Tajfel et al.
1971). However, research suggests that rather than indi­
viduals who identify strongly with their in-group – ranking
out-groups more negatively, as might be expected – those
who are positive about their in-group are also positive
about other groups (Hind et al. 2003). This finding is
attributed to wider contextual factors, such as membership
of diverse student groups of healthcare professionals.
These students were also more positive about IPE, suggest­
ing that a strong professional identity does not mitigate
against students’ willingness to engage positively in it. This
finding supports Clouder’s (2003) conception of ‘sociali­
sation as interaction’ based on social constructionist theo­
ries that suggest that society creates individuals, who, in
turn, create society (Berger and Luckman 1966). Socialisa­
tion as interaction allows socialisation to be seen in a less
deterministic way, especially if, as is advocated by the IPE
movement, students are exposed to one another in a way
that allows them to develop awareness of their profession
in the context of others.
Clouder’s research findings suggest that repressive and
deterministic socialisation processes are mitigated by the
potential for individual agency. Rather than being envel­
oped by the influence of professional discourses, ‘scarcely
aware of changes to their own identity’ (Clouder 2003:
220), she has suggested that they are capable of individual
agency able to make choices; options include conformity
and deviance, commitment or non-commitment, attrac­
tion or aversion (Vanderstraeten 2000). Clouder suggests
that such choices result in individuals’ differential posi­
tioning within their professional culture, either identifying
wholly with it or sitting on its fringes. Fringe positions
may be conducive to making connections with others in
different professions as they are inhabited by individuals
who have decided where they sit within their profession,
who then have the confidence to explore wider interpro­
fessional practice.
34
Calls to discuss the need for ‘re-professionalisation’
are based on the recognised need for individuals to shift
their identity and commitments from being profession-
focussed to the organisation in which they work (Hafferty
and Light 1995). The previous discussion suggests that
professional identity might be the foundation on which
individuals can go forward to optimise teamwork,
al­though research by Baxter and Brumfitt (2008) suggests
that, again, contextual factors, such as team size and
regular contact, were important in developing team iden­
tity, rather than professional identity. Professional identity
and its interaction with interprofessional relations and
interprofessional learning is clearly complex. In agreement
with Kreber (2010), we suggest that it might be helpful to
think of (professional) identity formation as essentially
intersubjective, dialogical and relational in nature. Team­
work is an important element, but, perhaps more impor­
tantly, Wackerhausen (2009: 471) reminds us that ‘our
professional means come and go but our professional
raison d’etre stays. That is, relentless searching for and using
the most excellent means available to do the best we pos­
sibly can for the patient’. Accepting this raison d’etre is part
of our professional identity that takes us closer to effective
interprofessional practice.
CONCLUSION
The importance of IPE in preparing undergraduates for a
world of work where co-ordinated collaborative practice is
the norm should not be underestimated. By engaging in
IPE students are able to experience, in a safe environment,
the complexity of joint working and the ways in which
individual professional sensitivities can, and do, get in the
way of decision-making, as well as culminating in a less
linked and more fragmented experience for patients. IPE
is a useful precursor to improved collaborative working;
today’s practitioners need to be capable of working across
boundaries and providing seamless holistic patient care
with colleagues. In 1988, the WHO called for IPE on the
basis that learning together translates into improved
working together (WHO 1998).
This chapter has sought to provide the reader with an
overview of the current thinking around IPE within the
context of contemporary health and social care practice,
as well as instil in the reader a sense of its importance
in the preparation of graduate health and social care
practitioners.
As the historical perspective shows, IPE is not a new
concept and yet there is still much work to be done on
securing a robust evidence base to support the investment
both educators and practitioners put into its ongoing
inclusion in education programmes, which both prepares
new graduates and supports the ongoing professional
development of the health and social care workforce.
 Collaborative health and social care, and the role of interprofessional education
The authors of this chapter have highlighted the impor­
tance of IPE in the undergraduate curriculum to help
prepare graduates for a world of work where collaborative
practice is becoming increasingly the norm. The publica­
tion of the most recent NHS white paper: ‘Liberating the
NHS’ (DH 2010a) reinforces the requirement for collabo­
rative practice in health and social care. For all practition­
ers this means that every opportunity to develop those
skills required for effective collaborative practice should
be seized.
For undergraduates concerned with learning to be a
particular type of professional with all the inherent uni-
professional requirements this demands, the inclusion of
IPE can sometimes be viewed as less valuable than those
uni-professional aspects. The authors of this chapter hope
to convince readers that IPE is an important aspect of their
undergraduate education. It is possible to learn to be a
particular type of professional within an interprofessional
learning context.
Learning to be an effective physiotherapist in the twenty-
first century necessitates active engagement in IPE. IPE
provides opportunities to practise and experience collabo­
rative working in a safe environment. Learning is a process
not performed in isolation from others. As Wenger (1998)
asserts, learning involves collaboration and engagement
between learners, each influencing and, in turn, being
influenced by each other; learning outcomes become
shared by communities of practice. IPE is a natural place
for this to occur.
Social learning theories (Wenger 1998) suggest that
learning with, and through, interaction with others builds
communities of practice. This chapter has tried to high­
light the importance of interprofessional education as a
way of developing the knowledge skills required for col­
laborative working. It can be argued that building com­
munities of learning through engagement in IPE is the
best way to develop such knowledge and skills. IPE com­
munities of learning provide a safe environment where
undergraduates can test out their own professional role
and identity alongside peers from other professional
groups doing the same. Collaborative learning, practice
and work are never easy, and are difficult to negotiate
on a daily basis. However, it is imperative that today’s
practitioners are able to practise such professional nego­
tiation on a daily basis if they are to practise person-
centred health and social care. IPE offers a vehicle to
support this and through collaboration between profes­
sionals lead to:
• improved services;
• improved health outcomes;
• effecting change.
The importance of working closely with other profes­
sionals to provide care that is truly focussed upon people
and their families cannot, and should not, be underesti­
mated (DH 2000b; Wilcock et al. 2009). Being an effective
Chapter 2
physiotherapist means being equipped with the knowl­
edge, skills and values distinctive to physiotherapy, and
recognising, understanding and valuing the knowledge
skills and values distinctive to other professional groups.
Physiotherapists who are confident in their own profes­
sional knowledge, skills and values will be able to recog­
nise when they are the best professional for the job and
when it is more appropriate for another professional
to do the job. IPE as a mechanism for promoting more
effective collaboration and team-working can help to
prepare graduates for the daily negotiation of professional
boundaries as an integral part of work in order to provide
patient-centred care.
The benefits of IPE are well documented and this
chapter has introduced readers to the history, drivers, key
concepts and practices of IPE alongside an exploration of
some of the complexities inherent in any collaborative
endeavour (including IPE). The authors acknowledge the
need for more evidence to substantiate the benefits of IPE
as a precursor to effective collaborative work practices;
however, the growing evidential base (Horder 2004;
Bokhour 2006; Stone 2006; Lennox and Anderson 2007;
Weblinks
Australasian Interprofessional Practice and Education
Network (AIPPEN): http://aippen.net/index.html
Canadian Interprofessional Health Collaborative (CIHC):
www.cihc.ca
Centre for the Advancement of Interprofessional
Education (CAIPE): www.caipe.org.uk
European Interprofessional Education Network (EIPEN):
www.eipen.eu
Global Health Workforce Alliance:
www.who.int/workforcealliance/en
Health Professions Global Network: http://hpgn.org/
International Association for Interprofessional
Education and Collaborative Practice (InterEd):
www.interedhealth.org
Japan Interprofessional Working and Education Network
(JIPWEN): http://jipwen.dept.showa.gunma-u.ac.jp/
Journal of Interprofessional Care:
http://informahealthcare.com/jic
National Health Sciences Students’ Association (NaHSSA):
http://nahssa.ca/en/gateway
Nordic Interprofessional Network (NIPNet):
http://nipnet.org/
The Network: Towards Unity for Health:
www.the-networktufh.org
World Health Organization (WHO): www.who.int/en
London Deanery: Interprofessional Education
http://www.faculty.londondeanery.ac.uk/e-learning/
interprofessional-education/Interprofessional%20
education.pdf
35
 Tidy’s physiotherapy

Clarke 2006; Cooper and Spencer-Dawe 2006) is testa­
ment to the enduring interest in IPE. Current political and
societal drivers (DH 2010a, 2010b) continue to ensure that
IPE and interprofessional working remain a high priority
in health and social care. As West et al. (2006) assert, more
positive patient outcomes are realised through greater and
more effective collaboration between professionals. IPE
that puts patients at the centre promotes collaboration
between professionals, reinforces professionals’ collabora­
tive competence and relates collaborative learning to col­
laborative practice (Horder 2004; Hendrick and Khaleel
2008; Wilcock, 2009).

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39
 Chapter
Clinical leadership
Alison Chambers
INTRODUCTION
The NHS, like all health care systems, is the
sum total of the people who work in it and the
day-to-day interactions they have with patients
and colleagues. A health care system is a
powerful coalition of organisations and
professions, not just a set of individual
organisations operating in a market. The way
to achieve transformation is through the
mobilisation of our staff to drive change. For
this to happen, our clinical and managerial
leaders need to understand what it is that we
are trying to do, and how it connects with our
wider values.
(Sir David Nicholson, NHS Chief Executives Annual
Report, 2007)
The purpose of this chapter is to introduce readers to the
concept of clinical leadership within the context of con-
temporary healthcare and suggest ways in which clinical
leadership can help to support and promote improved
health outcomes for patients. It is essentially an introduc-
tion to the idea that clinical leadership is an integral aspect
of every health professional’s professional day-to-day
practice.
While the need for strong and effective leadership in
healthcare is well recognised there is still the need for
ongoing exploration of how leadership in healthcare con-
tributes to improving health outcomes (Hardacre et al.
2010). Work by Hardacre et al. suggests that leadership for
improvement is culturally sensitive, inclusive, team-based,
3 
personal and collective (p. 27). There is, however, a growing
body of evidence that links leadership, culture in organisa-
tions and improved outcomes and quality (Corrigan
2000). Research into nursing leadership (Edmonstone
2011) suggests a direct link between effective nurse team
leadership and the quality of team work. In essence, effec-
tive leadership is seen as essential to improving health
outcomes. National Health Service (NHS) organisations
have and continue to invest significant amounts of
resources to developing existing and aspiring leaders, and
leadership competence in healthcare. Work by Hardacre
et al. (2010) suggests that some leadership behaviours
appear to be positively associated with service improve-
ment work and that service improvement work is begin-
ning to show links to improved health outcomes.
The chapter includes some real life leadership stories
that help to bring to life the day-to-day experiences of
clinical leaders. These stories are powerful in that they
enable real life experiences to be shared to show how dif-
ferent approaches to leadership are enacted in practice.
What these stories also do is demonstrate how leaders
cannot achieve anything alone, that leaders need teams in
order to help them achieve their goals. In the words of
Mike Farrar (Chief Executive, NHS North West):
Today’s NHS leaders don’t face their multiple
challenges alone: our leaders have teams,
directorates or organisations to meet the
challenges and achieve goals. Our job as leaders
is not to come up with solutions alone, but to
inspire people we lead to place ladders together,
against appropriate walls…
(Hartley and Bell 2009)
Narrative research utilises stories as a way of explor-
ing and, therefore, understanding more fully the lived
41
 Tidy’s physiotherapy
experiences of human beings (Mishler 1990, 1999;
Reissman 1997). Leadership narratives are very powerful
as a way of understanding human action and interac-
tion. The stories of real leaders doing the very real job
of leading NHS organisations have influenced the
writing of this chapter.
What this chapter does not do is provide the reader with
leadership theory. Readers are able to access leadership
theory through a wide range of leadership and manage-
ment textbooks, and readers are directed to Jumaa and
Jasper (2005) and Jarvis et al. (2003) as a starting point.
Constraints of space and constraints of purpose have
allowed the author of this chapter to take a practical
approach to the subject, drawing upon published litera-
ture but, more importantly, drawing upon real examples
of clinical leadership. In this way, the chapter attempts to
bring clinical leadership to life and to drive home its
importance to readers.
By using the NHS leadership qualities framework (LQF)
(NHSi 2009) alongside broader leadership concepts, the
chapter includes descriptions and illustrations of clinical
leadership in contemporary healthcare. It will provide a
brief overview of the healthcare reform context (readers
are directed to other chapters in this book for more detail),
describe, in some detail, the elements of the LQF and,
through this, explore some of the implications for today’s
physiotherapists. The chapter concludes with some practi-
cal advice on how physiotherapists can take personal
responsibility for developing their leadership credentials.
When reading the leadership literature it is apparent that
the concept of leadership is used in a wide variety of ways
and tends to be described in behavioural terms (Jumaa
and Jasper 2005; McDonald et al 2009; Hardacre 2010;
King 2010; Edmonstone 2011). This varied use of nomen-
clature and definition can be confusing for those new to
leadership writings. Put simply, leadership is concerned
with individuals and teams achieving what it is they set
out to achieve. The leader is someone who provides the
focus and sets the direction of travel but achieves an
outcome through the collective actions of the whole team.
The very essence of leadership is its purpose.
And the purpose of leadership is to accomplish a
task. That is what leadership does – and what it
does is more important than what it is and how
it works…
(Col. Dandridge Malone)
CONTEXT
Contemporary healthcare is complex and undergoing the
biggest change since its inception in 1948 (DH 2000,
2001, 2008, 2010). Although we all think of the NHS as
one big organisation, in reality it is made up of many
42
different organisations, each with its own culture and ways
of working. These NHS organisations have been undergo-
ing a radical change programme for over ten years and are
currently in the middle of another reorganisation, proba-
bly its most radical yet. As the government’s white paper
(2010) states, at its best the NHS provides world class care;
however, there is still some way to go before world class
care is experienced throughout the vast organisation(s)
that we call the NHS.
Just like any other large organisation in today’s climate
of austerity and economic challenge, the NHS is charged
with ensuring efficient and effective working, raising
standards and redesigning services to improve the quality
of the patient experience (DH 2008, 2010). This is a
particularly challenging time for the NHS: redesigning
services and the workforce that delivers the service, raising
standards, and improving efficiencies and real-term sav­
ings requires strong leadership. Leadership is not just the
responsibility of the most senior managers but the respon-
sibility of all staff, of whatever level, who work within the
NHS and who are charged with improving healthcare out-
comes (NHS North West Leadership Academy 2008; DH
2008). Also, the creation of a new Public Health Service
located within local government rather than as an integral
part of the NHS will require professionals to work much
more collaboratively, with a greater impetus toward ensur-
ing that multi-service, interprofessional, inter-agency
working and collaboration are the norm (DH 2010).
Readers are directed to Chapter 2 for more details and
references on collaborative working.
All organisations need financial investment, technical
knowledge, access to a market, political impetus, profes-
sional expertise and quality equipment, etc. (NHSi 2009)
and the NHS is no different. All organisations need leaders
who can utilise resources effectively and efficiently in
order to create success (NHS Alliance 2007). Strong leader-
ship creates an environment where success is more likely
to happen. The size and scale of NHS reorganisation and
proposed health reform creates a highly challenging and
complex context. This context creates an environment
where many organisations are focussing on identifying
and developing existing and potential leaders as a way of
effectively leading and managing the reform agenda. Argu-
ably, organisations that survive are those that have a strong
focus on leadership development practices and have a
shared understanding of what good leadership means
(NHS Alliance 2007; McDonald et al. 2009; Towill 2009).
A lot of attention has been focussed upon developing
individual leaders; Edmonstone (2011) calls for a rebal-
ancing to refocus attention on context and relationships
rather than individual leaders, thus emphasising the
importance of a collaborative approach to improving
services through a distributed leadership model (NHS
North West Leadership Academy 2008; NHSi 2009).
The Department of Health’s (DH) ‘High Quality Care
for All: Next Stage Review Final Report’ and the ‘High

Partner
In care delivery
with individual and
collective responsibility
for the performance of
health services and the
appropriate use of resources
High Quality
Workforce
Leader
Practitioner Expected to provide
Primary duty to clinical leadership and where
practice, delivering high appropriate take up
quality care based on senior leadership and
patients' individual needs management posts
Quality Workforce: Next Stage Review Report’ (2008) were
two important documents that provided the impetus for
leadership development throughout the NHS. These docu-
ments put the spotlight on the quality of care provided, as
well as the concept of care for all, as a means of ridding
the NHS of inequity and inequality of provision inherent
in some parts of the system (DH 2008). The most recent
white paper continues to emphasise the centrality of the
quality agenda in the provision of patient-centred care.
The shift to a truly patient-centred health service – ‘no
decision about me without me’ (DH 2010: 9) – requires
clinicians to rise to the leadership challenge.
A ‘High Quality Workforce: Next Stage Review’ (DH
2008) highlighted three aspects of every clinician’s role,
now and in the future. These aspects remain relevant today
and are likely to remain so for a long time. The three
aspects are described as: Practitioner, Partner and Leader.
Figure 3.1 describes how each different aspect can contrib-
ute to the high quality workforce required to deliver high
quality, improved healthcare.
THE ALLIED HEALTH PROFESSIONS
AND PHYSIOTHERAPY
The planned NHS reconfigurations as outlined in ‘Equity
and Excellence: Liberating the NHS’ (DH 2010) along
with existing NHS service reconfigurations, for example
transforming community services and the quality,
Clinical leadership Chapter 3
Figure 3.1  Contributory factors to a high
quality workforce.
improvement, prevention and productivity (QUIPP)
agenda (DH 2009), provide a context that demands effec-
tive leadership.
From an Allied Health Professions (AHP) perspective,
leadership development is a high priority. The Department
of Health Leadership Challenge events (2009, 2010) are
testament to this and readers are directed to the DH
website for further details (www.dh.uk). Across England
there are regional AHP networks all engaged in regional
leadership development as a way of framing the contribu-
tion of AHPs in delivering a world-class patient-centred
service (e.g. www.nhsnw.uk/ahpnetwork). Also, the AHP
career framework (Skills for Health 2007), which was
created in response to the ‘Modernising Allied Health
Professions Careers’ project (DH 2002), emphasises the
importance of leadership.
The Chartered Society of Physiotherapy’s newly pub-
lished physiotherapy framework (CSP 2010) includes the
knowledge, skills and values required of effective clinical
leaders. This framework was the product of a lengthy
project called ‘Charting the Future’, and defines and
illustrates the knowledge, skills, behaviours and values
required for contemporary physiotherapy practice (CSP
2010). This framework not only underpins contemporary
practice, it is also the basis from which undergraduate and
postgraduate physiotherapy education is developed. It
describes physiotherapy practice at all levels, across differ-
ent professional roles, across a variety of settings and
across all four nations of the UK. Readers are directed to
www.csp.org.uk for further details.
43
 Tidy’s physiotherapy
Key points
• Leadership is seen as being key to the implementation
of health reform in the NHS (Firth-Cozens and
Mowbray 2001; Gobillot 2007; Hartley and Bell 2009).
• Government health policy reform calls for increased
clinical leadership to deliver a world class NHS service
(DH 2000, 2002, 2008, 2010; NHS Alliance 2007).
• Regulatory and professional body frameworks include
leadership competencies as an integral part of health
professionals’ initial and continuing professional
development and education across a career trajectory
(Skills for Health 2007; HCPC 2007; CSP 2010).
• Commissioning high quality healthcare requires
frontline clinician engagement (Corrigan 2000;
King 2010).
• The NHS requires clinical leaders who infiltrate all
areas of NHS organisations (McDonald et al. 2009;
Towill 2009; Edmonstone 2011).
• Leadership is every clinician’s business (Janes and
Mullan 2007; NHSi 2004).
• There are well recognised links between leadership
capability and sustained high performance (Fillingham
2007; Gobillot 2007; Hardacre et al. 2010).
• Management and leadership talent are the most
important features of organisations (DH 2007;
Fillingham 2008)
• The National Clinical Leadership Council supports
clinical leadership development.
(N.B. the nomenclature ‘clinician’ is used throughout
this chapter to denote the full range of all healthcare
professionals engaged in direct clinical care, irrespective
of their professional background. It is intended to
emphasise the point that the whole healthcare team
shares equal responsibility for improving the health
outcomes of patients.)
Just as there is a lack of commonality in the use of the
concept ‘leadership’, the term clinical leadership is still
being defined and refined (Cook 2001; Stanley 2006).As
this chapter is primarily about leadership in the NHS, it is
useful to provide a definition of clinical leadership. The
definition below is useful in that it emphasises the impor-
tance of leadership as action rather than as leadership
relating to position:
Someone who whether in a formal or an
informal position in an organisation who
demonstrates particular skills and behaviours
that accord with both professional and
organisational values and that result in
improvement in service delivery, safety and
quality whilst at the same time engendering the
active support of colleagues and peers…
(NHS North West Leadership Academy 2008)
44
NHS leadership qualities  
framework (LQF)
The LQF was created specifically to provide a common
language and approach for leadership in the NHS (NHSi
2009). It was designed over a two-year period by the Hay
Group and launched in 2002 by the then NHS Chief
Executive and Permanent Secretary to the Department of
Health Sir Nigel Crisp. It was reviewed most recently
by the NHS Institute for Innovation and Improvement
(NHSi) in 2006.
It is said to reflect the culture of the NHS and is designed
to be flexible and intuitive, and allows for individual self-
reflection (see Chapter 5 for further details). A widely-
available framework, the LQF allows individual clinicians
to analyse their own leadership roles and therefore can
be a useful self-development tool. The LQF sets the
standards for outstanding leadership and describes the
qualities expected of existing and aspiring leaders. Within
the LQF there are 15 leadership qualities clustered into
three groups:
1. Personal Qualities
2. Setting Direction
3. Delivering Service.
Each cluster describes the key characteristics, attitudes
and behaviours required for effective leaders at all levels
(NHSi 2009). Full details of the LQF can be found at
www.nhsi.nhs.uk.
This next section will describe each cluster of leadership
qualities and relate them to how you may begin to reflect
upon your own abilities and strengths, as well as begin to
identify your development needs. The descriptions below
are adapted from the LQF. A complete version of this can
be found at www.nhsi.uk. Readers are also directed to
Griffin (2009) for examples of use in practice.
Personal qualities
The personal qualities required of successful leaders are:
self-belief, self-awareness, self-management, a genuine
drive for improvement and a high level of personal integ-
rity. Demonstrating these qualities through everyday prac-
tice is important. Self-belief means standing up for what
you believe in and not being afraid of doing so, even
when others seem to hold an alternative view. Being
aware of how your behaviour impacts on others is key to
effective leadership – your own actions and emotions
will have an impact on those you work with; this impact
can be positive or negative. Reflection can help you to
explore these qualities in yourself by thinking about, and
critically evaluating, your own experiences. Being able to
manage yourself is vital if you are going to be able to work
within, and cope with, increasingly complex environ-
ments. Healthcare was never straight forward and today’s
practice is certainly not. It is forever changing, diverse and
increasingly complex.

Task
Think about some of the successful leaders you have
come across either in work or in other aspects of your
life, for example sport and school, and try to remember
how they demonstrated the personal qualities listed
above.
Think about how you demonstrate these personal
qualities. Reflect upon your own personal qualities and
begin to think about which aspects you may need to
develop.
Setting direction
Setting direction means being able to articulate a vision
and a direction of travel which others can understand, see
and feel able to achieve. In order for leaders to be able to
do this they need to be able to exploit all opportunities to
bring about improvements by understanding and inter-
preting the drivers for change, such as those described in
earlier sections of this chapter. Intellectual flexibility
means being receptive to fresh insights – being willing
to see things from a different perspective other than your
own. It is about being open to professional conversations
that challenge our way of seeing the world. This can help
us to support and encourage our own creativity, as well as
that of our colleagues. It can be extremely liberating to
discuss and suggest new insights and solutions to old
problems.
In order to set direction appropriately leaders need to
keep themselves informed about key developments; they
usually have a range of networks that enable them to
benchmark themselves and their teams against peers in a
systematic way. Being receptive to standing in patient and
service user’s shoes and seeing things from the point
of view of a user of the service they are providing helps
to provide a unique insight impossible to get in any
other way.
Task
Think about successful teams you have worked with and
reflect upon what made the teams successful.
Reflect upon a time when you have taken a lead role
in a team. How did you set direction for yourself and the
rest of the team?
Delivering service
In order to deliver world class services, leaders need to
work through others. Individual’s spheres of influence
tend to be restricted to a small number of individuals. This
Clinical leadership Chapter 3
means that leaders have to rely upon others to effect a
change. Spheres of influence show us that leaders rely
upon those they influence to then influence others, and
so on – a little like the ripples in a pond when a stone is
thrown (NHS Alliance 2007; Hartley and Bell 2009;
Hardacre et al. 2010).
Delivery of services relies upon leaders being able to
lead change through others, hold people to account for
the work they do, empower others to take the lead,
and influence through effective partnerships and collabo-
rative working (see Chapter 2). In order to effectively
lead, individuals need to be able to gain the support
of others, be prepared to share leadership through em­­
powering and enabling others, and be able to hold
people to account.
Task
Reflect upon your own team-working successes. How did
you go about building relationships and partnerships?
What strategies did you use?
Think about a time when you have taken the lead.
How did you empower others? How did you measure
your success in a leadership role? What, if anything, did
you learn from the experience and how do you intend to
develop your abilities?
As other chapters in this textbook have highlighted, no
one healthcare professional can be a universal panacea for
the healthcare needs of patients. Collaborative working is
essential if we are to deliver on the promise of world class
healthcare. Leaders therefore need to be capable of effec-
tive and strategic influencing, able to work in partnership,
cope with ambiguity, understand diverse view points and
strive to create an environment where successful partner-
ship working can thrive.
The impetus for collaborative partnership working is
reinforced by the National Clinical Leaders Network
(2009) whose principles reinforce the need for collabora-
tion and describe them as improving clinical leadership
and engagement, improving quality, and influencing
policy and service reform across professions, specialty,
service and organisations (Farrar 2009).
COMMISSIONING WORLD CLASS
HEALTHCARE SERVICES: THE ROLE
OF CLINICAL LEADERSHIP AND
SERVICE IMPROVEMENT
In 2007 the NHS Alliance (see www.nhsalliance.org)
published a document that describes and showcases
examples of Allied Health Professions (AHPs) leading
45
 Tidy’s physiotherapy
change in the NHS. This document describes the relation-
ship between clinical leadership and world class commis-
sioning. Clinical leadership at all levels is an essential
component for change leading to improved services and
health outcomes. Clinical engagement is required for com-
missioning and it can only happen if clinical leadership
infiltrates the entire workforce (NHS Alliance 2007). Com-
missioning the right health services for the provision of
high quality health services reduces health inequalities
and improves the health of local populations. In simple
terms commissioning involves:
• identification of need;
• securing services to meet the need;
• performance-management of the service;
• evaluation of the delivery of services.
It requires:
• knowledge;
• resources;
• action;
• time-management of change.
(NHS Alliance 2007)
The proposed health reforms put GPs in the driving seat
of commissioning healthcare across the English health
system (readers are directed to the Scottish, Welsh and
Northern Irish governments for details of these country’s
health service systems); in other words, putting clinicians
in the frontline. This requires clinicians to be engaged in
the commissioning agenda. What commissioning involves
and requires is what frontline clinicians can provide and
every clinician has a responsibility to engage with it. Front-
line clinicians have knowledge of patient needs and the
services required to meet those needs. Clinicians deliver
the service and therefore are well placed to lead service
and workforce redesign initiatives. Through research,
clinical audit and other outcome-measurement metrics
clinicians are also capable of evaluating the service they
provide and measuring patient outcomes qualitatively
and quantitatively. Thus, clinical engagement is of central
importance and can only be achieved if clinical leadership
is distributed throughout the workforce.
Clinicians at all levels require enabling and empowering
to develop their own leadership competence to be
effective.
Leadership is action not position…
Donald H. McGannon
So, as commissioning is the driving force behind the
provision of high quality health services there needs to be
a high level of clinical engagement in commissioning in
order to ensure that the best services are commissioned.
Clinical engagement is essential for world class commis-
sioning. Clinical engagement is only possible where clini-
cal leadership is distributed throughout organisations and
professional groups.
46
Service improvement
Clinical leadership is an important requirement to
achieving the ambitious healthcare reforms described in
the white paper. Another essential aspect of health reform
is the modernisation of services through service redesign/
reconfiguration, and service improvement and workforce
redesign (Batalden and Davidoff 2007; NHSi 2009;
Wilcock et  al. 2009; DH 2010). The Institute of Health-
care Improvement in Boston pioneered the application
of quality improvement in healthcare. From 2001 to 2004
the Modernisation Agency (MA) in the UK promoted the
same (NHS MA 2004). Subsequently, the MA’s successor,
the NHS Institute for Innovation and Improvement,
continues to promote quality improvement in healthcare
(Batalden et  al. 2002; Fillingham 2007). Similar ap­­
proaches are taken in a number of other regions,
including Scandanavia, Australia and the Netherlands.
It is well recognised that service improvement is the
responsibility of all healthcare professionals. It transcends
professional boundaries, puts patients at the centre of
healthcare decision-making, and requires co-operation
and collaboration across agencies, organisations, services
and professional groups. As Batalden and Davidoff (2007:
80) assert, achieving service improvement requires the
commitment of all professionals on a daily basis as part
of everyday professional practice: ‘the ideal conditions for
this are when everyone working in health care recognises
that they have two jobs when they come to work every day
to do their job and improve it’. Leadership underpins col-
lective action, providing truly patient-centred healthcare
requires individuals and groups of professionals to take
collective action.
In order to make service improvement an integral part
of everyday life of clinicians, the NHS will need strong
and effective leadership that transcends professional and
organisational boundaries and which pervades every
corner of organisations (Batalden et al. 2002; Wilcock
et al. 2009). In order to meet the demand for healthcare
now and in the future the NHS will need to implement
the health reform agenda through staff who are empow-
ered to lead service improvements designed to improve
health outcomes in a patient-led NHS (DH 2010). This
will require clinical leaders who are able to work collabo-
ratively, across traditional boundaries and, importantly,
learn to see the service they provide through the eyes of
their patients.
Clinicians at all levels need to learn to see beyond what
they normally see. As David Fillingham says when intro-
ducing lean healthcare, in his book about his personal
leadership journey as the Chief Executive of an NHS trust:
… it is amazing how blind we can become in
our day to day work to the errors and problems
that exist all around us … we are often so
preoccupied with the demands of our job that

we stop seeing the service through the eyes of
the customer … learning to see the service as
they see it is critical to identifying the
opportunities for improvement…
David Fillingham (2008: 55)
Thus, clinical leadership and service improvement go
together. As earlier parts of this chapter have outlined,
service improvement will only be successfully sustained
if clinical engagement is achieved. Clinical engagement
is promoted through clinical leadership. Therefore, the
development of leadership qualities is fundamental in
providing world class healthcare.
High quality healthcare has been described as clinically
effective, personal and safe (DH 2008). Despite best
efforts, there are still some areas of the NHS that do not
achieve this (DH 2010). At its best, the NHS provides a
world class service. Ongoing and newly proposed health
reforms are the way in which a world class NHS for all is
thought to be achievable. Improving care at the frontline
requires continuous quality improvement (DH 2000;
Janes and Mullan 2007). Continuing quality improvement
requires professionals to work together. No one profession
has all the answers; professionals have to share knowledge
and skills with each other to achieve the best health out-
comes for patients.
Since the inception of the MA over ten years ago, there
has been an extensive NHS-wide change programme. This
modernisation programme has led to a radical overhaul
of NHS services and the NHS workforce. NHS organisa-
tions have undertaken a radical service improvement
programme which has led to redesigned services, the
development of clinical pathways of care, and a redesigned
NHS workforce to meet the changing and increasing
health demands of the public. Professional development
of existing NHS staff has included service improvement
methodology and, increasingly, service improvement
learning is included in the undergraduate programmes
which prepare a wide range of professionals for practice
(Janes and Wilford 2007; NHSi 2008). As already
described, service improvement involves clinical engage-
ment and clinical engagement requires clinical leadership,
hence its importance and inclusion in this textbook.
Fusing learning about improvement with doing real
improvement work has become a key driver (Aron and
Headrick 2002).
The case for clinical leadership
The DH Operating Framework 2007 confirmed the impor-
tance of clinical leadership in delivering improved services
for patients.
… it is the very nature of the reforms that
improvements must be owned by clinicians,
managers and other frontline staff on the
Clinical leadership Chapter 3
ground … it is the responsibility of the NHS
community leadership … to engage fully with
clinicians. Staff, patients and the wider public
to communicate and explain the need for
change and the potential of reforms locally to
improve services and people’s lives…
(DH Operating Framework 2007/8: 36)
The NHS Next Stage Review Interim Report 2008, led by
Lord Darzi, further emphasised the responsibility of clini-
cians to lead change in the NHS in response to the public’s
need: ‘the essence of clinical leadership is to motivate, to
inspire, to promote the values of the NHS and create a
consistent focus on the needs of patients’ (DH 2007: 37).
SOCIAL INTERACTION, SPHERES OF
INFLUENCE AND PROFESSIONAL
PRACTICE EXAMPLES
Within everyday life we are continually interacting with
people around us. This interaction creates an environment
where we both influence and, in turn, are influenced by
others (Goffman 1959; Jenkins 2004). This interaction
impacts how we behave and what we do. The same can be
said of everyday professional practice. Everyday profes-
sional practice involves us in interaction. In other words,
what we do and how we do it is affected by those around
us. This interaction creates what is called a sphere of influ-
ence for each and every one of us. This sphere of influence
is associated with our position in organisations and we
each have a limited sphere of influence dictated by where
we sit in organisations and with whom we interact. These
spheres of influence occur through social interaction.
We all have spheres of influence and it is through these
spheres of influence that we can affect those around us.
Exercising clinical leadership can help us to use our
spheres of influence to effect positive change wherever we
find ourselves and whatever our position in organisations.
Effective influencing is key to effective leadership (see
NHSi 2009).
The new CSP physiotherapy framework (2010) describes
clinical leadership as an integral aspect of a definition of
physiotherapy. Physiotherapy is defined as ‘a health pro-
fession that works with people to identify and maximise
their ability to move and function’ (CSP 2010). It states
that physiotherapy has strong clinical leadership and an
adaptable workforce able to deliver high quality links
between education and research. It describes the four ele-
ments of physiotherapy practice, physiotherapy knowl-
edge, skills, values and generic behaviours – knowledge
and skills shared by all clinicians working in healthcare.
The CSP framework divides these generic elements into
two sections relating to interaction, and problem-solving
47
 Tidy’s physiotherapy

and decision-making. For more details, readers are directed

to Chapter 1.
All the elements described in the physiotherapy frame- Case load
work share aspects that are also integral to clinical en­­ MDT
clients
gagement and leadership, collaborative working and
accountability. The framework reflects the context of
contemporary healthcare, including the reform agenda Advanced
associated with continual service improvement. practitioner
sphere of
The diagrams below provide examples of spheres of
Other influence
influence at different career levels, advanced support Students
physiotherapists
worker, advanced practitioner and expert practitioner, thus
demonstrating that we can both influence and be influ-
enced in order to effect service improvement (Figure 3.2).
Note that these are suggestions of what spheres of
Professional
influence may look like and are not intended to be organisational and
exclusive. national networks

Task Case load

clients
Draw on your own sphere of influence and write down
ways in which you exercise your influence within the
sphere. Reflect upon how you think others influence you Other
in return. Describe the strategies you use to influence MDT
physiotherapists
effectively. Think of ways of expanding/changing your
sphere of influence. What strategies can you develop to Expert
improve your influencing? sphere of
influence

Policy makers Students

DEVELOPING YOUR LEADERSHIP

COMPETENCIES Professional
organisational and
national networks
The previous sections have outlined some of the reasons
(including other
and the professional drivers of why we should all be con- professionals)
cerned with developing ourselves as leaders. Within our
own spheres of influence we can begin to influence those
around us by having the courage to share our knowledge
and skills and work in a collaborative way across profes-
sional boundaries. We can begin to contribute to improv- Clients
ing the quality of healthcare and contribute positively to
health reforms which are focussed on improving health
outcomes through our clinical leadership. This next
section will provide you with some practical ideas for you Advanced
to consider as a way of developing your own leadership Support support worker Delegating
competencies. workers sphere of physiotherapists
influence

Organisational requirements
In order for leaders to develop in their organisations a
number of factors are required. Not least there needs to MDT
be a shared understanding of what leadership looks like.
Remember, the NHS is made up of a number of distinct
Figure 3.2  Spheres of influence. Adapted from CSP Framework
2010 (CSP 2010).

48

organisations, each with their own culture and ways of
doing things and so it cannot be guaranteed that each
NHS organisation behaves in the same way as the next.
The LQF provides a framework for leadership; it cannot,
however, control how it will be interpreted and operation-
alised in each and every organisation.
Organisations need to value the role of leadership,
reward it and be open and willing to share leadership
experiences. For example, chief executives of NHS organi-
sations in the north-west of England have all contributed
to a book called Placing Ladders; Harnessing our Leadership
Potential (Hartley and Bell 2009), which shares their lead-
ership stories. This is a very powerful book in that it
describes the first-hand experience of very senior leaders,
many of whom are humbled by their experiences of listen-
ing to and learning from patients about the care they
received in their hospitals. These very senior leaders rec-
ognise and value the contribution of all their staff and
celebrate success collectively. Some share some painful
stories as a way of writing about their leadership approach
(see Chapter 3 ‘Making Spaces’ in Morley 2009). The
power of stories as a legitimate form of understanding and
making sense of lived experiences cannot be underesti-
mated (Reissman 2008). These stories provide a very real
insight into what some of today’s NHS leaders do in the
process of leading their organisations. Hardacre et al.
(2010) propose ways in which leadership can influence
improvements in healthcare outcomes as a result of their
research into the links between NHS leadership and
improvement.
Figure 3.3 describes the components required for leader-
ship development within organisations.
Organisation culture
Shared understanding
of leadership
Clear expectations
of leaders
Leadership valued
Sharing leadership
throughout the organisation
experiences/learning
A distributed leadership
across professions,
(Leadership as action
services, organisations
and not positional)
Career structures to
Organisational and
support career aspirations
individual support for
and good performance
leadership development
rewarded
Clinical leadership Chapter 3
Individual requirements
There are a number of ways in which we can begin to
systematically think about ourselves in a leadership role.
Many of the skills we use to support the development
of our professional knowledge and skills can also be used
to support our leadership competencies and are described
in more detail in other chapters of this textbook. This
final section suggests ways of supporting your personal
learning. This list is not exhaustive but does include
some of the more commonly used approaches that pro-
fessionals use to support their professional development.
Some of those listed involve social learning approaches.
Social learning theory suggests that learning is a collective
endeavour, achieved through, and by, interaction with
others via communities of learning. Readers are directed
to Wenger (1998) for more details. Other approaches
described involve a more individualised approach to
learning. A common theme throughout is experiential
learning (Boud et  al. 1985; Jarvis et  al. 2003). Experiential
learning is most often associated with adult learning
and professional learning in practice (Eraut and Hirsh
2007). The author does not propose that any particular
approach is better than another. You will find some of
the approaches listed below more helpful than others;
this will reflect your own particular learning style and
particular organisational context. The important thing to
remember is to explore a number of learning approaches
to find the one that suits your way of learning and
provides you with the support you find most helpful.
• Action learning sets. Small groups of clinicians
(often from different professions) coming together
Figure 3.3  The components required for leadership
development within organisations. Individual
requirements.
49
 Tidy’s physiotherapy
on a regular basis to share and learn from the
experiences of group members. Often involves a case
study type of approach where one member will
describe an experience in order to stimulate
discussion in the group around possible solutions/
future actions.
• Mentoring. A supportive one-to-one relationship
where either a more senior professional mentors a
more junior colleague or peers mentor each other.
Can be uni- or interprofessional. Mentor and mentee
meet on a formal/informal basis. Both mentor and
mentee agree the parameters of the one-to-one; focus
is on the needs of the mentee.
• Coaching. Similar to mentoring but usually much
more structured to provide stretch and challenge to
support career development around competency
development at a particular stage in a career, for
example when seeking promotion or when newly
promoted and development needs have been agreed.
Often used to support executives and senior staff in
organisations.
• Reflection. Usually involves individuals describing
day-to-day experiences in order to learn from
successful and not-so-successful experiences in order
to improve their own professional practice. These
reflections can often provide the experience that
individuals bring to a collective/social learning event
(see Chapter 5 for more details).
• 360 degree feedback. Usually undertaken as part of
leadership development programmes and involves
self-assessment and colleagues’ assessment of skills
and abilities to provide a comprehensive assessment
of ability that can be used to identify strengths and
learning needs. Individuals ask a number of
colleagues to assess them, including the line
manager, peers and subordinates in order to provide
a full, 360 degree perspective. Can be a very powerful
tool for individuals to assess self-perception against
how others perceive them.
• Professional networks. Both uni- and
interprofessional in nature. Virtual and physical
bringing together of clinicians to share knowledge.
Often used as a forum to discuss topical issues, for
example health reforms and policy issues. Can be
used to provide a collective response to
consultations. Examples include regional
physiotherapy boards, AHP networks, clinical
manager groups, National Clinical Leaders Network
and the AHP Confederation. Building and
maintaining professional networks are key to
benchmarking yourself against peers and can be a
very powerful way of triggering reflection.
In practical terms, none of the above are mutually exclu-
sive. For example, while coaching is quite often undertaken
on a one-to-one basis, often action learning sets involve
50
individual members coaching each other within the
action learning episode. Professional networks usually
support a large number of professionals in broadly generic
ways through virtual and physical network communities;
they also incorporate specific programmes to support
members. For example, the NHS North West AHP network
has developed a comprehensive coaching network for
members to access as part of their specific developmental
needs (www.nhsnw/ahpnetwork.uk). Leadership develop-
ment is important to enhance the quality of leadership in
organisations and there are many formal learning oppor-
tunities available for clinicians to access. And, of course,
there are many formal award-bearing learning programmes
available, such as Masters level programmes specifically
designed to meet the needs of health service managers.
It is assumed that readers of this text are familiar with
the process and practice of reflection as an integral aspect
of being a physiotherapist and are directed specifically to
Chapter 5 for revision. Clinical leadership is about taking
individual and collective responsibility for your day-to-
day practice and striving for continual service improve-
ment and improved patient experience.
The development of clinical leadership should begin as
an undergraduate and continue throughout your career.
Remember, clinical leadership is not about the position
you hold in an organisation but rather about a way of
behaving and acting. It is acknowledged that often the
position a person holds in an organisation does put them
in a powerful position from where they can assert their
leadership. However, if graduates are to be ready to take
on the challenge associated with clinical leadership then
it follows that their leadership development must begin as
an undergraduate. This can be daunting for undergradu-
ates; however, there are a number of ways in which under-
graduates can begin to test out their leadership skills, such
as putting yourself forward to be a student representative
or taking part in service improvement initiatives as part of
your undergraduate programme where opportunities exist
(NHSi 2008; Janes and Wilford 2007), seeking opportuni-
ties during your clinical placements (on top of, and in
addition to, developing your profession-specific knowl-
edge and skills) to observe or get involved in service rede-
sign programmes, actively participate in multidisciplinary
team meetings and take the initiative to discuss service
improvements with your clinical educator and other clini-
cians through professional conversations.
Developing leadership qualities in clinicians helps to:
• engage them in service reform;
• address service delivery frustrations;
• develop evidence-based effective practice;
• reduce service and clinical variations;
• increase efficiencies;
• promote reflective practice;
• increase capacity and capability.
(NHS Alliance 2007)
 Clinical leadership Chapter 3

clinicians in the driving seat. The complexity of today’s

CONCLUSION
The focus on developing clinical leaders at all levels of
NHS organisations remains a key priority (DH 2010). This
chapter has provided the reader with an overview of clini-
cal leadership and the context in which it is developing
and evolving. Political, professional and organisational
imperatives demand that every clinician, irrespective of
professional allegiances, rises to the leadership challenges
ahead to improve the quality of healthcare to improve
health outcomes. While it is acknowledged that the evi-
dence of a causal link between NHS leadership and
improved services remains scant, there is a wealth of evi-
dence through personal leadership stories of NHS leaders
to support the ongoing investment in leadership develop-
ment. Challenges for clinical leaders are vast. The NHS
is a complex organisation made up of many distinct, yet
connected, organisations charged with unprecedented
integration and reform. The shift towards healthcare com-
missioning through general practitioner consortia puts
healthcare requires an interprofessional approach to
service development, delivery and improvement. The
interdisciplinary nature of healthcare demands wide
spread clinical engagement in commissioning; this can be,
and is being, achieved through clinical leadership. The
clinical leaders of tomorrow need to recognise the impor-
tance of leadership as an integral aspect of their profes-
sional life and practice.
Leadership is about individuals and multilevel
leadership … about translating concepts and
ideas so that they have meaning for colleagues
working with patients, designing services or
considering patient needs. It is about building
commitments and agreement to go forward
addressing population and service needs,
changing services, delivering services…
(NHS Alliance 2007: 13)

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 Chapter
Pharmacology
Nicholas T.L. Southorn
INTRODUCTION
Pharmacology?
This chapter is a new addition to Tidy’s which represents
the innovative and forward motion of the profession of
physiotherapy. Greater independence and autonomy as
primary care practitioners with direct access means that
physiotherapists have to demonstrate an understanding of
medical conditions and treatments, including medicines.
The clinical picture painted from the subjective assessment
involves drug history; therefore, the need to understand
how to interpret this information is essential lest the
picture be smudged and the patient’s care compromised.
Clinical pharmacology is an entire science; this is a
chapter within a book. In no way will it cover the entire
breadth and scope of the topic, but rather provide a brief
overview of the application of basic scientific knowledge
regarding common medicines encountered by the physi-
otherapist. This information should be adequate for your
studies, but I hope to light the touch paper of an explosive
interest in pharmacology which you may fuel further by
reading the recommended texts at the end of this chapter.
A basic physiological knowledge is expected to be enough
to understand pharmacology; however, where possible,
the relative physiology will be explained. Please note that
Chapters 12 and 17 may be a useful starting point.
Please see the end of this chapter for a reference glossary
of pharmacology terms and some common drugs.
What is pharmacology?
Simply, it is the study of medicines and their interaction
with the body. Information is needed from the moment
the drug enters the body and, indeed, how it got there,
4 
how it travels to the site of action, the physiological actions
and their consequences, and how it is metabolised and
excreted.
When talking about a drug, the typically accepted
method is as outlined in Table 4.1.
Example
Ibuprofen may be taken by adults orally in tablet form
at 400 mg three times per day off prescription (four
times per day on prescription) or applied to the skin as a
cream. Its anti-inflammatory action is that of non-specific
inhibition of cyclooxygenase (COX)-1 and COX-2, thus
inhibiting prostaglandin production. It is a weak acid and
is absorbed largely in the stomach with a peak plasma
concentration of one hour. It is metabolised by the liver
and excreted in the urine. Owing to the non-specific
nature of the COX inhibition, its side effects include
alteration of the mucosal lining of the stomach (reduced
bicarbonate excretion = reduced lining defence against
hostile acidic environment so increased H+ secretion
exacerbates the acidity of the stomach) and renal
vasoconstriction. Therefore, it is contraindicated in
those with compromised kidney function and prone
to gastric ulcers.
This is all you need to know about ibuprofen for the
adult in one paragraph, simple!
However, this chapter herein avoids using this method
for two reasons:
• you should be making notes that require you to
gather information from different sources, which will
help you learn in more depth;
• it is rather repetitive for me to write and you to read!
53
 Tidy’s physiotherapy
Why would I, a physiotherapist or a
student, want to know about this?
If you have a detailed understanding of the action of the
drugs in question you may understand how long it takes
to act, how some drugs may have multiple uses, why doses
of drugs may differ significantly when taken via different
routes and how the drugs may be altering the patient’s
perception of pain. You will also appreciate how your
practice impacts upon the uptake of drugs, for example
the application of heat near a transdermal patch or the use
of relaxation.
The clinical picture, as previously mentioned, needs to
be complete; poor medical knowledge may lead the clini-
cian to jump to erroneous conclusions.
Examples
DRUG = THE PATIENT MUST HAVE…
Metformin = diabetes
Amitriptyline = depression
Gabapentin = epilepsy / seizures
These are all quite natural assumptions – ones that
would be enforced by looking at the British National For-
mulary (BNF); however, metformin may be used for poly-
cystic ovary syndrome, amitriptyline for sleeping problems
and neuropathic pain, and gabapentin for neuropathic
pain. So, when you read the past medical history: don’t be
sold a kipper – understand the possibilities.
On the ward, you must know your patient’s past medical
history; for example morphine may influence certain res-
piratory techniques; spinal anaesthetics may make one
think twice about mobility assessments; a patient’s dizzi-
ness may be caused by certain antibiotics, for example
streptomycin, etc.
It is common for people to go to their local shop and
buy some over the counter (OTC) medication. However,
Table 4.1  What you should know
Drug The name of the drug
Route and dosage Orally, injected, rectally,
transdermal, etc.
Pharmacodynamics What the drug does to the body
Pharmacokinetics What the body does with
the drug
Metabolism/excretion How is the drug eliminated
Side effects Including contraindications/
precautions, etc.
54
they don’t always take these appropriately – you need to
know if they are over- or under-dosing and advise appro-
priately. Also, are they contraindicated by any of the pre-
scribed medication? Does the medical prescriber know
what the patient is taking? This point is particularly perti-
nent when the patient is taking herbal medications –
asking them to chat to their family doctor regarding this
is always recommended.
Picking up on these pharmacological red flags is as
important as picking up any other type of red flag. So, the
next time a patient tells you that they are taking three
500 mg of paracetamol six times per day or St John’s wort
to help with their depression, you might decide to advise
the patient to discuss these issues with their general
practitioner.
So, as a physiotherapist, you should care and the profes-
sion as a whole should embrace pharmacology for the
sake of patient safety.
BASIC SCIENCE
Where do drugs act (Table 4.2)?
Their action will ultimately have an impact on the cell to
which the surface protein is attached, and therefore the
tissue, organ and system in which the cell resides. A cell
has three main options during normal function: excitation
– such as that of a depolarised neurone – contraction or
secretion. The drugs will affect the cells’ ability to express
themselves either making them more active, less active or
maintaining normal function by blocking other sub-
stances from affecting them (Figure 4.1).
How may drugs get to their
destination?
Drugs must be absorbed, i.e. they have to get from the
outside in. The main routes of administration are:
• oral;
• sublingual;
Table 4.2  Protein/chemical interactions
Drugs basically target specific proteins, thus:
Receptors e.g. morphine
Enzymes e.g. angiotensin-converting
enzyme inhibitors
Ion channels e.g. local anaesthetics
Transporters (carrier e.g. proton pump
proteins) inhibitors
 Pharmacology Chapter 4

A
• rectal;
Receptors
Direct
Ion channel • epithelial surface application (skin, nasally, corneal,
opening/closing etc.);
Enzyme • inhalation;
activation/inhibition
Agonist Transduction
Ion channel
• injection (subcutaneous, intramuscular (i.m.),
mechanisms
modulation intravenous (i.v.), etc.).
DNA transcription These routes each have additional factors which will con-
tribute to how well the drug is absorbed, for example:
No effect
Antagonist Endogenous mediators blocked
• blood flow;
• gastrointestinal motility;
• size of drug particle;
• dissociation constant (kPa/physiochemical factors of
the drug; see the Glossary term ‘pH and ionisation’
B Ion channels for details).
Blockers Permeation blocked Wherever they are heading, they will need to cross a mem-
brane along their way. They will do this in one of the
following ways:
Increased or decreased
Modulators
opening probability • diffusion through the lipid bilayer;
• transmembrane carrier protein;
• pinocytosis (invagination of the cell membrane
creating an intracellular vesicle);
Enzymes
• diffusing through a special aqueous channel.
C
Normal reaction The ionic status of a drug molecule is significant when
Inhibitor
inhibited considering membrane transit. To traverse the lipid bilayer,
a molecule should be non-polar and unionised (without
False Abnormal metabolite charge). As many drugs are weak acids or bases, this
substrate produced presents a complication. The pH of the environment will
alter the ratio of ionised to unionised molecules, thus
influencing the diffusion of the drug across the membrane.
Pro-drug Active drug produced Simply, an environment (pH = acidic or basic) that pushes
up the relative number of unionised species will increase
its ability to permeate the membrane, thus more drug will
be absorbed. If the drug is an acid, A-, (e.g. aspirin) in an
environment with a low pH (e.g. the acidic gastric juices
D Transporters
of the stomach, pH = 3) it will gain a hydrogen ion, H+,
and thus become unionised, AH, and cross the membrane.
Normal To clarify, an acidic drug is better absorbed in an acidic
transport
environment and a basic drug is better absorbed in an
alkaline environment. It begins to stretch the scope of
this chapter to delve any deeper, but for a better under-
Transport standing see the Henderson-Hasselbalch equation and
Inhibitor or
blocked
dissociation constant (kPa) in any good pharmacology/
clinical physiology book.
False Abnormal compound Blood flow may be influenced in your practice as
substrate accumulated a physiotherapist via heat, relaxation, massage, chest per-
cussion, acupuncture, electrotherapy, etc. If the area to
which the drug has been delivered has a good blood
Agonist/normal substrate Abnormal product supply, for example gut, skin, mucosa, it will be absorbed
more rapidly. Also, a drug that enters the systemic circula-
Agonist/inhibitor Pro-drug tion but acts locally, for example ibuprofen, may have
Figure 4.1  Drugs act on many parts of the body a higher concentration in the injured area if the blood
including (A) receptors (B) ion channels (C) enzyme and flow is enhanced. It is always worth considering if
(D) transporters. Reproduced with kind permission from Rang and you wish to influence this mechanism of drug absorption.
Dale’s Pharmacology (Figure 3.1: p.25). Copyright Elsevier 2008. An often-quoted scenario is the patient who has a

55
 Tidy’s physiotherapy

transdermal morphine patch and is advised to apply heat
to their shoulder. In doing so, the patient’s uptake of
the drug was enhanced and experienced associated side
effects.
The sympathetic response is part of the ‘fight or flight’
reaction. Part of the sympathetic effect is to decrease the
gastric blood flow in favour of skeletal muscle and reduce
peristalsis (this is the fight or flight response which is
explained in exquisite clarity in Payne’s Handbook of Relaxa-
tion Techniques: A Practical Guide for the Health Care Profes-
sional). By encouraging relaxation you will allow the
parasympathetic nervous system to resume control and
allow normal absorption of drugs and food from the gut
(Figure 4.2).
Inhaled drugs (including oxygen), bronchodilators
and cystic fibrosis transmembrane regulator therapy
require the lungs to be operational enough to utilise the
vast surface area and be clear enough so that excessive
secretions are not blocking the epithelial transport of the
drugs. The surface area and the capillary network allow
rapid uptake of the drug, which makes inhalational
therapy very useful indeed. Localised drug actions, such as
dilating bronchioles, are useful as the lungs also expel the
drug rather effectively, thus minimising the systemic
effects. This is arguably the biggest influence that a physi-
otherapist can have on drug delivery, as not only can you
mobilise secretions, you can facilitate the musculature to
enable deeper breaths and expand more lung.

Spinal Lateral chain

cord of ganglia Structures Effects of stimulation

Pupil dilated
Iris muscle
Slightly relaxed
Superior
Blood vessels in head Vasoconstriction
cervical
ganglion Salivary glands Secretion inhibited

Oral and nasal mucosa Mucus secretion inhibited

Skeletal blood vessels Vasodilatation

Rate and force of contraction

Heart
T1 1 increased
2
3 Coronary arteries Vasodilatation
4 Coeliac
5 Trachea and bronchi Bronchodilation
ganglion
6
7 Peristalsis reduced
Stomach
8 Sphincters closed
9 Peristalsis and tone decreased
Intestines
10 Vasoconstriction
11 Glycogen – glucose conversion
12 Liver
Superior increased
L1 1
L2 2 mesenteric Spleen Contracted
L3 3 ganglion
Adrenaline and noradrenaline
Adrenal medulla
secreted into blood
Peristalsis reduced
Large and small intestine
Sphincters closed

Kidney Urine secretion decreased

Inferior
mesenteric Smooth muscle wall relaxed
Bladder
ganglion Sphincter closed

Sex organs and genitalia Generally vasoconstriction

Figure 4.2  Sympathetic outflow; the observable signs of sympathetic stimulation may be useful in assessing the non-
communicating patient. Reproduced with kind permission from Payne’s Handbook of Relaxation Techniques (Figure 1.4: p.7). Copyright
Elsevier 2010.

56

Metabolism and excretion –   patient-controlled analgesia device. This ensures that the
the body gets hostile
Drug elimination is achieved by either metabolism
(change of the molecular shape and function) or excretion
(through urine, exhalation, faeces, etc.).
Once a drug has made its perilous journey from outside
of the body to within, the body sets about changing it: the
liver is the main site of metabolism. The main process of
metabolism is mediated by cytochrome P450 – a large
group of enzymes that alter the molecule of the drug and
the product (metabolite) may be totally inactive, active in
a completely different way or even more potent. Drugs
that are given for the purpose of being metabolised into
an active drug are called ‘prodrugs’.
A drug taken orally must pass into the portal circulatory
system from the intestines. This is a direct line to the liver
and therefore it undergoes pre-systemic metabolism (also
known as first-pass metabolism). It is essential to under-
stand that this happens as the amount of available drug
in the plasma is a fraction of the amount given orally (the
actual fraction is called ‘bioavailability’). The result is that
the drug which undergoes extensive first-pass metabolism
must be given in a higher dose orally than another route.
Other ways that the drug is eliminated is through excre-
tion via urine. The clearance of a drug depends on many
factors, including plasma binding, glomerular filtration,
lipid solubility and pH, etc.
A note on dosing
All of the above needs to be calculated for efficacious
delivery of the drug. The dose needs to be enough to ‘work’
in the therapeutic window but not too much to create side
effects.
Figure 4.3 is a basic representation of delivery of i.v.
morphine. An initial bolus dose is given until analgesia
is achieved and then a top-up is given, perhaps by a
Side effects
Plasma concentration
Therapeutic
window
Symptoms
Time
Figure 4.3  The therapeutic corridor must be aimed for and
maintained, otherwise the side effects are too great or the
symptoms are not controlled.
Pharmacology Chapter 4
plasma concentration is always in the therapeutic window.
It is important to convey the information to the patient
in an accessible way because they may not understand why
they need to take some medications regularly when they
only occasionally get symptoms, and some medications as
and when required.
MEDICINES YOU WILL (PROBABLY)
ENCOUNTER
All medications taken by the patient should be known to
all involved in their care.
The heart and vascular systems
You should be aware of cardiac physiology as part of your
course. Normal function of the heart depends on the rate,
rhythm, contractility, blood supply and autonomic
control. Drugs acting on the heart fall into three main
groups:
• direct action on myocardial cells (anti-dysrhythmic
drugs, inotropes, etc.);
• indirect cardiac function (diuretics, angiotensin
converting enzyme (ACE) inhibitors, etc.);
• calcium antagonists.
Anti-dysrhythmic drugs are typically applied during emer-
gency cardiac events in adjunct to, or in place of, physical
treatments, such as electrical cardioversion (e.g. defibril­
lator). They include drugs that block voltage-sensitive
sodium channels thus inhibiting the action potential, for
example lidocaine (a local anaesthetic) will associate and
dissociate within the time frame of a normal heartbeat,
thus normalising the rate. It essentially pauses all electrical
activity in order to allow normality to resume. It is deliv-
ered i.v. as it has a very low bioavailability (see above). It
is metabolised rapidly, giving a short half-life, thus allow-
ing rapid alteration of plasma concentration to avoid the
central side effects of drowsiness and convulsions. Another
action is that of β-adrenoceptor antagonism which effec-
tively reduces sympathetic expression on the heart by
increasing the refractory period of the atrioventricular (AV)
node (i.e. slowing the heart’s pacemaker). These drugs,
such as propanolol and atenolol, have the unfortunate
side effect of bronchospasm, fatigue and bradycardia, but
in the absence of lung disease the risk is relatively low.
Another class of anti-dysrhythmic drugs are calcium antag-
onists and are discussed below in more detail.
Increasing cardiac contraction may require poison. The
extract of the foxglove (genus Digitalis) is used as a cardiac
glycoside (e.g. digoxin). The effects are reduction of con-
duction, increased force of contraction and disturbance
of rhythm. They enhance vagal activity and inhibit the
57
 Tidy’s physiotherapy
Na+/K+ pump, thus increasing the twitch tension in cardiac
muscle. It is given orally (i.v. in emergencies) but unfortu-
nately the clinical risk of such drugs is the fine line between
effectiveness and toxicity. It is excreted via the kidneys
which poses a problem in patients with less effective renal
function in terms of maintaining plasma concentrations
at a safe level.
Angina is an important symptom which indicates insuf-
ficient oxygen supply for cardiac activity. It is controlled
by either increasing perfusion or reducing demand (or
both). Two important drugs that you may encounter are
glyceryl trinitrate (GTN) and isosorbide mononitrate.
These organic nitrates are metabolised into nitric oxide
which initiates a cascade of effects resulting in relaxation
of vascular muscles and therefore reduced central venous
pressure (and thus preload and afterload of the heart),
reducing stroke volume and metabolic demand. The relax-
ation of coronary arteries will enhance the oxygen delivery
to the myocardium. GTN is given orally by spray or sub-
lingual tablet (owing to extensive first-pass metabolism it
is ineffective if swallowed). It acts within minutes and is
rapidly metabolised by the liver and effectively eliminated
in half an hour, hence its usefulness in acute situations.
Isosorbide is similar, but is taken as a tablet and lasts
longer in the system which makes it a useful prophylaxis
for angina.
Calcium antagonists block entry of Ca2+ to the cell
by acting on voltage gated channels. Drugs such as vera-
pamil and diltiazem are used occasionally for their anti-
dysrhythmia action, but this group of drugs is more
commonly used for hypertension (e.g. amlodipine and
nifedipine). The action on the heart is generally a comp­
licated balancing act but the effects of the arterial and
arteriolar smooth muscle is relaxation, thus reducing
peripheral resistance (and hence blood pressure). They
are well-absorbed and thus taken orally, for example
amlodipine is taken once daily because of its long
half-life.
The renin-angiotensin system is of significant importance
in terms of fluid volume and vascular tone. Renin is
released by the kidneys and converts angiotensinogen into
angiotensin I (AT1) which is converted by ACE into the
potent vasoconstrictor angiotensin II (AT2). The ACE is a
epithelial membrane-bound enzyme particularly abun-
dant in the lungs and is the site of action for the anti-
hypertensive ACE inhibitors (e.g. ramipril and captopril)
whose action is simply to block the active site of the
enzyme, thus preventing the formation of AT2.
Statins help reduce the levels of low-density lipoprotein
cholesterol (LDL-C) which adhere to damaged blood
vessel walls as part of the athrogenesis chain reaction
which ultimately results in significant vessel damage. The
action is rather complex and involves an understanding of
the mechanism of cholesterol transport and lipoprotein
metabolism that exceeds the scope of this chapter. Suffice
to say, they reduce circulatory HDL levels (see Chapter 20
58
of Rang and Dale’s Pharmacology for more detail). Examples
of common statins are simvastatin, atorvastatin and prav-
astatin. As a physiotherapist, it is worth remembering
that statins commonly cause muscle pain, so additional
medical history may be required relating to how long they
have been taking statins: does the pain correspond?
Usually, by alerting the prescriber, the problem may be
resolved by reducing the dose or changing the drug.
Diuretics increase NaCl excretion and thus water excre-
tion. They are used to reduce oedema and decrease the
load of the circulatory system on the heart. The most
potent of these drugs are loop diuretics (e.g. furosemide),
which inhibit transit of Na+, K+ and 2Cl− ions in the loop
of Henle. They are typically given orally or i.v. in acute
pulmonary oedema. Another example is the thiazides (e.g.
bendroflumethiazide), which are more often used to treat
simple hypertension. They act on the distal tubule binding
to, and inhibiting, the Na+/Cl− transport system which
increases the loss of NaCl. A caution with these diuretics
is the loss of K+ ions which is important to monitor in
patients who also have cardiac conditions requiring
digoxin. An unwanted side effect of thiazides is erectile
dysfunction. Potassium-sparing diuretics, such as spironol-
actone, are weak diuretics but they inhibit the secretion of
K+. These are particularly important to monitor as hyper-
kalaemia (too much potassium) can quickly become fatal.
The lungs
Bronchodilators that you will mostly come across are
known as β2-adrenoceptor agonists. They act on the β2-
adrenoceptors and therefore relax the smooth muscle,
enhance the ciliary clearance of mucus and reduce the
pro-inflammatory action of mast cells. They are usually
given by inhalation but oral tablets and injection prepara-
tions are also available. For acute episodes, salbutamol
and terbutaline are used because of their fast-acting nature
and reasonable duration of approximately five hours. Sal-
meterol and formoterol are used as a dose rather than in
acute situations as they take a little longer to act, but typi-
cally last much longer – approximately 8–12 hours. Other
bronchodilators include xanthenes, such as theophylline
or aminophylline (relaxation of smooth muscle but action
is unclear), cysteinyl leukotrine receptor antagonists, such
as montrelukast, and muscarinic receptor antagonists,
such as tiotropium or ipratropium (increases acetylcho-
line expression and reduces mucus secretion).
Anti-inflammatory drugs, such as glucocorticoids, reduce
the formation of pro-inflammatory cytokines and COX-2.
Steroids also reduce the allergic response in asthmatics by
inhibiting the specific cytokine that is responsible for regu-
lating mast cells – the eventual result is fewer mast cells
in the respiratory mucosa. They are given as a daily dose,
commonly by inhalation – known as a ‘preventer’ (beclom-
etasone, fluticasone, etc.). The full required response is
only achieved after weeks of continuous use, hence the

essential role of respiratory practitioners to ensure that the
patient understands how their drugs are to be taken. In
advanced cases, a tablet form is used (e.g. prednisolone)
to help bring the symptoms under control. In acute
exacerbations i.v. steroids are used for immediate anti-
inflammatory action to help maintain a patent airway. It
is important to note that side effects are rare but the
patient should only ever take steroids as directed by their
prescriber. Oral thrush may occur. All steroids have a
detrimental effect on the immune system and therefore
opportunistic viruses may take advantage.
Neurological medicine
Parkinson’s disease is associated with decreased dopamine
in the substantia nigra and corpus striatum, and effects
are typically tremor, muscle rigidity and hypokinesis
(reduced voluntary movement). Levodopa is considered
first-line treatment but is, unfortunately, extensively
metabolised into dopamine peripherally preventing it
passing through the blood-brain barrier and thus (i)
requires a very high dose to spare enough levodopa to
become centrally active and (ii) results in peripheral side
effects. These problems are overcome by combining levo-
dopa with an agent called carbidopa or benserazide that
helps prevent its peripheral conversion which reduces the
equipotent dose of levodopa to be reduced tenfold. Levo-
dopa is short-acting and so side effects revolve around
rapid alteration of symptoms ranging from dyskinesis
and hypokinesis to rigidity fairly rapidly. These effects
usually progress over time but more instant side effects
include nausea and vomiting, and postural hypotension.
Other treatment options increasing in popularity include
dopamine receptor agonists, such as pergolide, ropinerole
and pramipexole.
Anxiolytic and hypnotic drugs are widely used to reduce
anxiety, muscle tone, aggression, convulsions and to
help sedate patients. Benzodiazepines such as diazepam,
temazepam, nitrazepam, etc. act on γ-aminobutyric acid
(GABAA) receptors enhancing the effect of this inhibitory
amino acid in the central nervous system. This relaxant
effect helps to break the anxiety (for example dental pro-
cedures, flying, phobias, etc.) and sustained muscle con-
traction/increased tone (e.g. cerebral palsy, acute back
pain, etc.). They are typically well absorbed orally and
peak plasma concentration occurs within the hour. Side
effects include drowsiness and poor coordination, so the
patient is advised not to drive.
Antibiotics
The side effects of most antibiotics are nausea and vomit-
ing, gastrointestinal upset and skin irritation. However, if
you notice that a patient is taking an aminoglycoside they
may require a closer eye than normal. As with any antibi-
otic, you will want to know exactly why they are having
them from an infection-control perspective.
Pharmacology Chapter 4
Aminoglycosides are a particular type of antibiotic, the
most commonly seen are gentamicin, streptomycin and
neomycin. Usually given to treat Gram-positive cocci in
aerobic conditions, they inhibit the process of protein
synthesis from within the bacterium. Unfortunately,
the aminoglycosides are ototoxic, i.e. they damage the
sensory cells of the cochlea and vestibular systems
which is irreversible and will result in vertigo, ataxia and
dizziness, etc.
Analgesia/anaesthesia
Possibly the most common type of medication you will
come across in your medical career. Pain medication may
range from simple analgesia, such as paracetamol (aceta-
minophen) and ibuprofen to the extreme opioids and
local anaesthetics. You may also encounter adjunct anal-
gesia, such as amitriptyline and gabapentin.
Inhaled anaesthetics, such as nitrous oxide, halothane,
isoflurane, etc., work by inhibiting synaptic transmission
which peripherally block pain signals and centrally depress
areas of the midbrain associated with consciousness and
the thalamus associated with analgesia. As a physiothera-
pist you will probably only encounter nitrous oxide, N2O,
(when combined with oxygen at 1 : 1 ratio it is known as
Entonox) as it is used extensively in acutely painful situa-
tions, such as childbirth or sporting injuries. The effects
are extremely rapid and short-lived and the adverse effects
are few: patients with pernicious anaemia (deficiency of
vitamin B12) should avoid long-term use (longer than six
hours) as bone marrow depression may occur. Repeated
and prolonged usage may produce amnesia.
Opioids are any substances that act in a similar way to
morphine, while the term opiate is restricted to synthetic,
morphine-like drugs. Opium has been used for thousands
of years as a pain killer (and a recreational drug). The
morphine-like drugs are known as agonists (morphine,
diamorphine (heroin) and codeine), partial agonists
(buprenorphine) and antagonists (naloxone) depending
upon their expression on the cell (see the Glossary at the
end of this chapter for details). Opioid receptors have
three subtypes: µ, δ, and κ (mu, delta and kappa) which
contribute to the analgesia at different levels. The opioid
receptors are G-coupled receptors and the net effect is that
of inhibition of pre-synaptic release of neurotransmitter,
thus preventing nociception at the spinal level. While
achieving analgesia, strong opioids also produce euphoria,
especially if administered i.v. It is essential for all con-
cerned to understand the importance of the side effects of
morphine related drugs:
• sedation;
• respiratory depression;
• nausea and vomiting;
• peristalsis depression (resulting in constipation);
• histamine release (resulting in bronchoconstriction,
hypotension and itching).
59
 Tidy’s physiotherapy
In the event of an overdose, naloxone, an opioid antago-
nist, will block the receptors and rapidly reduce the effects.
Unfortunate consequences of prolonged use include
tolerance, whereby a higher dose is indicated for an
equi-analgesic effect, and dependence, whereby with-
drawal produces significant adverse physiological effects,
such as irritability, weight loss, shaking, etc. In essence,
morphine-like drugs are of vast importance but also a
considerable danger to the patient – care must always
be exercised when using them. Common opioids are
listed below.
Morphine is reasonably fast-acting, is metabolised into a
more potent form and has a half-life of approximately four
hours. Usually given i.v., orally as a tablet or syrup, or
transdermal patch. Commonly used in the community
and in acute settings.
Diamorphine (heroin) is used clinically, especially intra-
nasally for children in significant pain. Much faster-
acting than morphine and is metabolised into morphine.
Typically only used within hospitals. It has a high lipid
solubility which allows a much faster ‘rush’ compared
with morphine, but when taken orally its effects are
largely similar.
Methadone is commonly used for heroin addicts as it can
be much safer and has a much longer half-life (greater
than 24 hours). The side effect profile is as above but with
less euphoria.
Pethidine (aka meperidine in the USA) is given orally or
by i.m. injection, usually by midwives during childbirth
as, in contrast to morphine, it causes restlessness rather
than sedation and therefore dose not reduce the uterine
contraction force. With a shorter acting half-life (2–4
hours), pethidine is better controlled with little chance of
accumulation.
Buprenorphine is a partial agonist and is given as a sub-
lingual tablet or as an injection as the first-pass metabo-
lism is so extensive it is rendered inactive orally. It is
slow-acting with a predictable 12-hour half-life and less
respiratory depression than morphine, hence its common
usage in the community.
Fentanyl is delivered by epidural and transdermal patch.
It has a short-acting half-life (2 hours) and is highly
potent. Remifentanil (a variant form) is becoming increas-
ingly popular as it is faster-acting and is associated with
more rapid recovery.
Codeine/dihydrocodeine is used for mild pain and is
available to buy from pharmacies. It is a prodrug (it is
metabolised into morphine) and taken as a syrup or
tablets commonly combined with paracetamol. It is
approximately a fifth as potent as morphine but more
readily taken up when taken orally. Codeine is also used
as an antitussive (suppresses coughs) in children.
Tramadol is taken orally or i.v. It is generally well
absorbed and has a predictable half-life of 4–6 hours.
Although it has a weak opioid action, it also has a centrally-
acting action which inhibits the uptake of noradrenaline.
60
Tramadol is extensively used in the community for many
musculoskeletal conditions.
Non-steroidal anti-inflammatory drugs (NSAIDs) provide
symptomatic relief from mild-to-moderate pain associated
with inflammation. The oldest form is aspirin, which has
been in use since the late nineteenth century, and the
most common is ibuprofen. They typically act by the
inhibition of the COX enzyme and thus the production
of prostaglandin and thromboxanes, which are pro-
inflammatory. There are three identified isoforms of
COX (1, 2 and, more recently, 3) although the third
(also known as brain COX) may well not actually func-
tionally exist in humans. COX-1 is primarily involved,
although not exclusively, in the normal functions of
the human body: homeostasis, gastric protection, regula-
tion of renal blood flow and initiation of childbirth.
COX-2, among other things, is responsible for producing
pro-inflammatory mediators. Research in recent years has
shown that a COX-2-selective NSAID gives rise to throm-
botic events in those at risk and so most NSAIDs available
have little or no selectivity between the two COX isoforms.
Therefore, the side effects are considerable and the
patient’s past-medical history needs to be accounted for
if they are taking NSAIDs. The inhibition of prostaglan-
dins at the hypothalamus ‘resets’ the normal body tem-
perature which will have been affected by a bacterial
infection, thus producing an antipyretic effect.
Gastrointestinal disturbances are the most often cited
side effect of the NSAIDs, which are as a result of COX-1
inhibition. COX-1 products are responsible for the inhibi-
tion of acid into the stomach and maintenance of the
cytoprotective layer which protects the stomach lining
from the acidic gastric juices. Inhibition of COX-1 is det-
rimental to these essential components and, as such, the
stomach lining is under threat. The prostanoids responsi-
ble for renal blood flow are also a product of COX-1,
specifically PGE2 which dilates the vessels. Healthy indi-
viduals are at little risk but older patients, infants and
those with existing renal insufficiency are at particular
risk; therefore, NSAIDs with COX-1 inhibition (such as
ibuprofen) are contra-indicated. Approximately 5–10% of
patients with asthma will have a reaction to NSAIDs.
While aspirin and ibuprofen are the most common,
readily-available NSAIDs from pharmacies, there is a
whole range of NSAIDs, each with varying degrees of
COX-1 : 2 ratio and potency, etc. As a general rule, those
ending in ‘-fen’ are more weakly COX-1 selective and those
ending in ‘-coxib’ are COX-2 selective.
Paracetamol (aka acetaminophen in the USA) is one of
the most common analgesic drugs in the world. It can be
taken for mild-to-moderate pain and fever, and, although
classed as a NSAID, it lacks anti-inflammatory action
and associated gastric irritation. The action is largely
unknown as its action on COX-1 and 2 is limited: taken
orally, it is well-absorbed with a half-life of approximately
three hours. Between 5% and 15% of paracetamol
 Pharmacology Chapter 4

is metabolised into n-acetyl-p-benzoquinone imine
(NAPQI) which binds to hepatic and renal tubule cell
proteins, resulting in necrosis. However, in therapeutic
doses the body’s glutathione binds to NAPQI, allowing it
to pass harmlessly in the urine. In high doses, the concen-
tration of NAPQI exceeds safe levels, resulting in the slow
process of multiple organ failure. Paracetamol is com-
monly seen as a reasonable option for suicide but the
reality is rather unpleasant in all respects.
Tricyclic antidepressants (TCAs) (such as amitriptyline)
are very useful in the management of neuropathic pain.
They are considered to be an adjunctive analgesic as their
primary indication is not that of pain. They act centrally
by inhibiting the uptake of noradrenaline, which is inde-
pendent of their antidepressant action. It is rather impor-
tant to stress this to the patient, as they will automatically
assume that the doctor has declared them to be depressed
or as having a mental illness. This is entirely wrong and at
every opportunity they should be re-assured that this is
not the case. Side effects are generally sedation, so this
drug is normally taken at night.
Anti-epileptic drugs are also an adjunct used for neuro-
pathic pain. The Na+ channel blockers (phenytoin and
carbamazepine) target excessively depolarising cells – the
more frequently they fire, the larger the blockade. Clearly,
by blocking the sodium channels, they will arrest the
action potential. Calcium channels may also be targeted
by drugs, such as gabapentin and pregabalin. They target
T-type calcium channels, specifically the α2δ subunit
which helps to regulate the output of the neurones. The
side effects are ataxia and sedation, but the drugs are
usually well tolerated. As for the amitriptyline above, these
drugs are adjuncts to conventional analgesia and therefore
you must reassure the patient that these are also used
for pain.
Local anaesthetics such as lidocaine (lignocaine) and
bupivacaine deserve a special mention as many
orthopaedic medicine physiotherapists are now injecting
anaesthetics for a variety of painful conditions. Local
anaesthetics block the Na+ transport channels preventing
action potentials close to the site at which they are intro-
duced. They have a higher affinity to small-diameter neu-
rones than to larger fibres and therefore the nociceptive
Aδ and C fibres are targeted first. Motor neurones are
generally rather resistant. Although they are typically safe,
if they do enter the systemic circulation they may present
adverse effects, usually to the central nervous and cardio-
vascular systems. Their effect can be that of depression or
stimulation of the central nervous system, which may
result in convulsions, agitation and respiratory depression.
Cardiovascular effects are vasodilatation and depressed
myocardium, and therefore decreased blood pressure. For
the purpose of local nerve blocks, etc. an anaesthetist may
also mix in adrenaline to create vasoconstriction, thus
reducing the systemic distribution and prolonging the
effect of the local anaesthetic.
FINAL THOUGHTS
So, there you have it! Pharmacology is both relevant and
fascinating to learn about. You are not expected to under-
stand the minutiae of biochemical interactions (that is
what clinical pharmacologists/physiologists are for) but
please understand that your patients will have these drugs
acting within them as you treat: consider why, and how, it
will impact your clinical reasoning. Hopefully, you now
consider the prescribing route as a legitimate option as a
physiotherapist and would like to further enhance your
pharmacological knowledge. Above all, if you are unsure
about anything, make sure you find the answer before you
act. As a clinician, your career and the patient safety hangs
on your every action.

Pharmacology glossary
This glossary is intended to help break
down some of the barriers which may
be presented by the sometimes inac-
cessible language of pharmacology.
5-HT (5-hydroxytriptamine)
Serotonin – a neurotransmitter
Action potential (AP) The
transmission of a signal through
the length of an axon. This is
an all or nothing affair, i.e. to
stimulate an AP the depolarisation
must reach a threshold value after
which the AP is propagated,
regardless of the strength of the
initial stimulus. The resting
potential of the cell is −70 mV.
This is maintained by the active
transport of Na+ out and K+ in at a
ratio of 3 : 2. Stimulus will result
in Na+ channels opening allowing
sodium ions to rush in and the
membrane will begin to
depolarise. If this depolarisation
reaches approximately −55 mV
– the threshold value – it is a
successful stimulus and more Na+
flood in. At approximately
+30 mV potassium channels open
and K+ begins to leave the cell,
thus slowing the change of
potential across the membrane.
Once +40 mV is reached, sodium
channels close and repolarisation
begins as K+ is still leaving the cell.
At about −55 mV the potassium
channels close and normality
begins to return following a brief
hyperpolarisation. All of this
triggers off the same chain of
events in adjacent voltage gated
channels therefore sending the AP
down the axon
Adjunct analgesia A medicine
whose indication is something
other than pain, but whose
use provides analgesia
(e.g. amitriptyline)

61
 Tidy’s physiotherapy
Agonist, antagonist, partial
agonist, inverse agonist An
agonist will bind to a receptor and
produce an intracellular reaction,
whereas an antagonist will bind to
a receptor and have no action at
all (except for the physical aspect
of blocking a receptor site). A
partial agonist will exert a
submaximal reaction, but a
positive one nonetheless, and an
inverse agonist will inhibit normal
functioning of the cell, i.e. reduce
expression. An antagonist will
reduce the action of an agonist,
partial agonist and an inverse
agonist by competitive inhibition
Bioavailability The amount of
available drug in the blood
expressed as a percentage of the
oral amount given. Absorption
from the gut and first-pass
metabolism may reduce the
quantity of the drug reaching the
blood
Cyclooxygenase (COX) COX binds
to arachidonic acid on the inner
surface of the cell membrane acting
as a vital step in the production of
prostaglandins. COX-1 is the ‘good
guy’, responsible for vascular
homeostasis, gastric protection,
renal function and platelet
function. COX-2 is mostly the
opposite, enhancing gastric acid
and inflammatory mediators and
reducing gastric bicarbonate
secretion, etc. There is talk of a
‘COX-3’ which so far has only been
found in the brains of dogs. This
third isomer has sparked debate
regarding its contribution to
persistent pain
Elimination constant (Kel) The rate
at which a drug is eliminated
from the body
First-pass metabolism This is the
process that drugs entering the
system undergo when taken
orally. Once absorbed from the
gut, the drug is then transported
via the hepatic portal system to
the liver where it may undergo
extensive metabolism. This
pre-systemic assault course
reduces the amount of drug that
can act on the body and thus
gives rise to the concept of
62
bioavailability. This system may
be manipulated, however, as
inactive compounds may be given
which are then metabolised by
the liver into an active drug
– these are called ‘prodrugs’
G-coupled protein receptor (GCPR)
The GCPRs are very abundant and
highly important in drug actions
– they are a receptor positioned
on a cell membrane with
associated proteins within the cell
whose job it is to ignite a cascade
which completes whatever task
that particular cell does once
activated. A particularly important
GCPR is the opiate receptor whose
ligand may be endogenous (home
grown) or exogenous (e.g. a
codeine tablet). The resultant
action is inhibition of Ca2+ influx
at the neurone terminus
preventing release of
neurotransmitters into the synapse
Half-life (T1/2) The period of time
required for the plasma
concentration of a drug to have.
This is important for prescribers
to understand as it will influence
dosing
Metabolism Metabolism is the
enzymic conversion of one
chemical to another,
predominately by the liver. It is
part of elimination (the other
being excretion) which involves
removing the drug from the body,
but it may also be responsible for
producing active drugs, for
example morphine is metabolised
into the more potent
morphine-6-glucuronide
Neurotransmitters Chemicals that
are released across the synapse
after an action potential which
will excite the adjoining cell.
Examples include:
• acetylcholine (ACh);
• noradrenaline (NA);
• dopamine;
• opioids;
• histamine;
• serotonin (5-HT);
• adenosine.
Opiate receptor These are GCPR
receptors and found everywhere.
There are three main subunits to
think of: µ (mu), δ (delta), and κ
(kappa). A recent discovery is
called ORL-1. Their existence is
not to await the time of your life
when you rely on codeine or
morphine, etc. but to allow cell
activation from one of the body’s
own home grown (endogenous)
opioid peptides, such as
endorphins, enkephalins and
dynorphins. Each subunit has its
own particular outcome when
stimulated but all are involved in
pain analgesia. The overall effect
is to prevent the exocytosis at the
terminus of the neurone and thus
arrest the transmission of
nociception
pH and ionisation When
considering the transit of drugs
from outside the body through
wherever it is they are acting to
eventually being on the outside
again; it is important to mull over
the ionisation of the drugs in
relation to membrane
permeation. As drugs are either
weak acids or weak bases they
exist in a ratio of ionised and
unionised states which varies
with the environmental pH. The
dissociation constant, kPa, is the
pH at which the dissociated and
undissociated are equal and is
essential for predicting how a
drug will act in the body.
The ionised species (BaseH+
or Acid−) have low lipid
solubility and therefore may
not traverse the phospholipid
bilayer (except when specific
ion transporters exist). The lipid
solubility of the unionised
species depends upon it own
chemistry, but most are
sufficiently lipid soluble to
permit membrane permeation
Pharmacodynamics What the drug
does to the body! The
physiological action of the drug
and its manifestation in terms of
cell expression, symptom
alteration and pathology, etc.
Drugs work by:
• receptor mediation (opioids);
• enzyme inhibition (NSAIDs);
• ion channel modulation/
inhibition (local anaesthetics);

• carrier protein modulation/
inhibition (PPIs);
• physiochemical (antacids).
Pharmacokinetics What the body
does with the drug, i.e. how
is it absorbed/distributed/
metabolised/excreted, etc. The
route of administration plays a
huge part in kinetics, for example
oral medications undergo
first-pass metabolism where they
are taken through the portal
system and into the liver. They
also depend on a number of
factors, including pH, gut
motility, epithelial conditions etc.
Intravenous drugs have 100%
bioavailability and are rapid
acting. Transdermal drugs have to
be lipid-soluble to traverse the
subcutaneous tissue
Prodrug A drug that becomes
activated once metabolised by the
human body
Saturation kinetics The
disappearance of a drug from the
plasma may not follow the
exponential or bi-exponential but
rather a linear (removed at a
constant rate independent of
plasma concentration). This is
known as zero-order kinetics and
the former is known as first-order
kinetics. However, saturation
kinetics is a more user-friendly,
and functional, term. Essentially,
the plasma C is not relevant
when considering the rate of
elimination as in exponential
first-order kinetics owing to the
saturation of the elimination
mechanism. This is important as
these drugs (and ethanol is a very
common example), in high
doses, take a very long time to be
removed from the system. The
time taken for alcohol to leave
your system is therefore
proportional to the amount you
drink (assuming you drink so
much that you saturate the
elimination mechanism) whereas
a drug such as heroin will
initially clear much faster from
the system if more is taken,
meaning that taking twice the
amount does not take twice as
long to clear
Pharmacology
Single compartment model This is
a hypothetical idea aimed at
simplifying distribution, apparent
volume of distribution, Vd, and
drug administration. For example,
there is a body consisting of a
single, well-stirred compartment
into which a quantity of drug (Q)
is added rapidly by intravenous
infusion (IVI) and from which it
may escape by either metabolism
or excretion. The apparent
volume links the total amount of
drug in the body to its
concentration in the plasma. The
quantity of a drug in the body
when administered in a single
bolus is equal to the administered
dose, Q. Therefore, the
concentration at time 0 (C0) is
given, thus: C0 = Q ÷ Vd. In
practice, C0 is calculated by
extrapolation of the linear
portion of the semi-logarithmic
plot of concentration against
time, back to the intercept at
t = 0. Plotting Ct on a log against
linear t yields a straight line – the
inverse of this rate is the
elimination rate constant, kel.
While this is important to
understand elimination and
distribution of a drug, it is very
much worth reading it from a
dedicated pharmacology book!
Two compartment model This is
an approximation of distribution,
rather than the hypothetical
single compartment model. The
compartments are the peripheral
(all tissues) and central (plasma).
The effect of adding an additional
compartment develops a
bi-exponential curve, α, where the
drug leaves the first central
compartment and enters the
peripheral (no elimination
occurring yet), and, β, elimination
from tissues. This provides an
estimate of kel. Of course, this is a
very simple concept and lumping
all tissues into one ‘compartment’
is bad science
Volume of distribution, Vd
Distribution of drugs
is to plasma, extracellular fluid
and total body water. The volume
of distribution depends upon the
Chapter 4
molecular weight, lipid solubility,
ionisation and protein binding. A
drug must be lipid-soluble to
pass into cells and, in most cases,
the blood-brain barrier. Large
molecules and protein-bound
drugs will not leave the
circulation and therefore have a
low Vd. The distribution is an
exponential curve with an
α-phase denoted by the half life
(T1/2) whereby 50% of the drug is
removed from the plasma (by
distribution/metabolism). Some
drugs show zero order kinetics
whereby the elimination from the
plasma is constant – ethanol and
phenytoin are examples.
Drugs
Some basic information relating to
relatively important drugs which you
may come across in your practice.
Aciclovir (antiviral) Used to treat
infection by herpes virus
Adenosine (anti-arrhythmic)
Re-establishes sinus rhythm
following supraventricular
tachycardias (SVTs)
Adrenaline (epinephrine)
Stimulates heart activity during
arrest and increases blood
pressure by vasoconstriction.
Used for anaphylaxis caused by
bronchodilation and blood
pressure stabilisation. Also used
in conjunction with local
anaesthetics to prolong the effects
and reduce the risk of systemic
effects of the anaesthetic
Alendronate bisphosphonate
Reduces the rate of bone
absorption by inhibiting
osteoclast activity. Used primarily
for postmenopausal and steroid
associated osteoporosis
Alfentanil (opioid analgesic) Rapid
onset opioid chiefly used for its
respiratory depressive qualities in
ventilated patients. Also used
peri-operatively to enhance
analgesia
Aminophylline Bronchodilator
typically used for severe acute
asthmatic episodes – given i.v.
Amiodarone An anti-arrhythmic
used to slow conduction of the
63
 Tidy’s physiotherapy
nerve impulses and treat
tachycardia
Amitriptyline A tricyclic
antidepressant (TCA) which is
used more for neuropathic pain
than depression. Amitriptyline
competitively blocks binding sites
of amine transporters reducing
the uptake of 5-HT and
noradrenaline, thus increasing the
synaptic expression at the
synapse. This is cited as being a
mechanism of reducing depressive
illness by enhancing neurogenesis
and reducing apoptosis via gene
transcription. Amine re-uptake at
the bulbospinal pathway is a
reasonable explanation for the
downward inhibition of pain
Amlodipine (calcium channel
blocker) An anti-hypertensive
Aspirin An anti-inflammatory drug
used as an analgesic and antipyretic
in higher doses (300–900 mg)
and as an anti-platelet in lower
daily doses (75 mg)
Atenolol (beta-blocker) Used to
treat hypertension
Atorovastatin (statin) Reduces the
plasma HDL cholesterol levels
protecting against atherosclerosis
of the blood vessels
Atropine Blocks the action of
acetylcholine and thus relaxes
smooth muscle. Typical usages
include pupil dilation and
irritable bowel syndrome
Beclomethasone A corticosteroid
used as an inhaler for asthma.
This is used as a dosed drug
rather than as required because of
the accumulative effects
Bendroflumethiazide (thiazide
diuretic) A diuretic that may be
used for hypertension and oedema
Captopril (ACE inhibitor)
Prevention of the formation of
the powerful vasoconstrictor
angiotensin II and therefore
reduces blood pressure
Carbamazepine An anticonvulsant
used for treatment of seizures.
Also used for the pain associated
with trigeminal neuralgia
Chlorpromazine An antipsychotic
that sedates patients offering
relief of schizophrenia and severe
agitation
64
Cimetidine (H2-receptor
antagonist) Decreases the
secretion of acid into the stomach
relieving the symptoms of gastric
reflux/peptic ulcers, etc.
Codeine (opioid analgesic)
Relatively common opioid which
is approximately 20% the potency
of morphine. Usually sold in a
combined preparation with
paracetamol. Used to treat
mild-to-moderate pain
Diazepam (benzodiazepine) Used
to relax muscles and reduce
anxiety. Usually given to patients
in the community with acute
back pain and muscle spasms
Diclofenac Non-steroidal anti-
inflammatory (NSAID) for
mild-to-moderate pain
Dihydrocodeine AKA DF118
(opioid analgesic) An opioid that
is slightly more potent than
codeine but less potent than
morphine. Used for moderate pain
and often combined with
paracetamol in an over-the-counter
preparation from pharmacies
Erythromycin (antibiotic) A
bacteriostatic antibiotic with
similar spectrum effectiveness to
penicillin, typically very useful for
those with an allergy to
penicillin. Very common side
effects include diarrhoea,
vomiting, abdominal pain and
nausea as it is a motilin agonist.
Fentanyl (opioid analgesic)
Fast-acting with a short half-life
analgesic, typically used in acutely
painful situations
Ferrous sulphate This iron salt
tablet is prescribed to treat
anaemia
Fluoxetine (selective serotonin
reuptake inhibitor) An anti-
depressant that inhibits the
re-uptake of serotonin within the
synapse enhancing its effect on
the post-synaptic membrane.
Commonly known as Prozac in
the USA
Furosemide A very fast-acting
diuretic that can reduce
pulmonary oedema in
emergencies
Gabapentin An anticonvulsant used
to down-regulate hyperactive
nerves that cause seizures and
neuropathic pain
Gliclazide An anti-diabetic drug that
lowers blood sugar levels. Used in
type II non-insulin-dependent
diabetes mellitus (NIDDM)
Glyceryl trinitrate (GTN) Used in
the treatment of angina by
dilating the coronary vessels.
Delivered by a spray under the
tongue during acute episodes
Heparin (anticoagulant) Used as
prophylaxis against clotting (either
in deep vein thrombosis (DVT) or
pulmonary embolus (PE))
Hydrocortisone A steroid used to
treat inflammatory disorders
(such as rheumatic conditions,
psoriasis, etc.) and
immunosuppressant (for example
to prevent organ rejection /
reaction following transplant)
Ibuprofen (NSAID) A very common,
readily available anti-
inflammatory drug used for
mild-to-moderate pain as a result
of inflammation
Insulin (anti-diabetic hormone)
Given as an injection to lower
blood sugar in type I insulin-
dependent diabetes
Lansoprazole (proton pump
inhibitor) Used to reduce the
amount of acid secreted into the
stomach for those with gastric
reflux/ulcers, etc.
Metformin (biguanide) Decreases
glucose production as a treatment
for type II diabetes. This tablet is
normally given in conjunction
with gliclazide
Methotrexate (cytotoxic
and immunosuppressive) This
important drug inhibits normal
protein synthesis therefore leading
to cell death. It can be used in
inflammatory rheumatic disorders
and tumours, as well as leukaemia
Metoclopromide (dopamine
antagonist – anti-emetic)
A common anti-emetic used to
reduce the symptoms of nausea
and vomiting
Morphine (opioid analgesic) A
controlled drug used for severe
pain. Respiratory depression,
nausea and vomiting are the most
prominent side effects of note

Naloxone (opioid receptor
antagonist) An opioid antagonist
that can reverse the effects of an
opioid agonist such as morphine.
Often used in emergency
situations in cases of opiate
overdose. More recently, it can be
found in oral preparations in
conjunction with opioids such as
oxycodone to prevent the
constipation side effects
Naproxen (NSAID) A prescription-
only NSAID used for chronic and
generally more severely painful
inflammatory conditions
Odansetron A very effective
serotonin agonist used to treat
nausea and vomiting in
postoperative patients
Omeprazole (proton pump
inhibitor) Reduces the amount of
acid released into the stomach
Paracetamol (acetaminophen)
Classed as a NSAID despite its
limited anti-inflammatory
properties. Used commonly
for mild-to-moderate pain and to
help reduce temperature
(antipyretic)
Pethidine (opioid analgesic) Rapid
acting analgesic used for
moderate-to-severe pain,
ACKNOWLEDGEMENT
The author would like to acknowledge the help of Dr Douglas McBean PhD, Senior Lecturer in Physiology and Neuro-
science at Queen Mary’s University.
FURTHER READING
Rang, H.P., Dale, M.M., Ritter, J.M.,
Flower, R.J., 2012. Rang and Dale’s
Pharmacology. Churchill
Livingstone, Edinburgh.
Firstly, this is the book to have in your bag
if you are even slightly interested in
pharmacology. Reading this book is a
pleasure; the relaxed rhetoric, elegant
writing and subtle wit is evident
throughout the whole book with the added
benefit of actually learning something
(rather like Tidy’s Physiotherapy).
While it is a useful reference text, it is
possible to ‘read’ the book, as it flows
effortlessly from the history of
Pharmacology
especially during childbirth as it
lacks the sedative effect seen in
other opioids and therefore does
not inhibit uterine contractions
Prednisolone (steroid) Suppression
of inflammatory, immune and
allergic disorders. Also used in
organ transplant to help prevent
rejection
Pregabalin (anticonvulsant) Used
to help prevent seizures in epilepsy
and control neuropathic pain
Propofol An anaesthetic induction
agent and highly potent sedative
Ramipril (ACE inhibitor) An
anti-hypertensive that produces
peripheral vasodilatation
Salbutamol (β2 agonist for acute
asthma) Used in metered doses
through an inhaler for acute
asthmatic episodes. It is fast-
acting with a short half-life hence
why it is used as required
Salmeterol (β2 agonist as a dose)
Used in metered doses through
an inhaler but as a dose to help
prevent acute episodes of
bronchoconstriction. Compared
with salbutamol, it is slower-
acting but longer-lasting
Senna Used for constipation, it acts
as a stimulant for the colon
pharmacology, through the basics of
pharmacological science to the minute
detail of the drug types.
Neal, M.J., 2012. Medical
Pharmacology: At a Glance.
Wiley-Blackwell, Oxford.
Secondly, those who like concise details
with no frills will love this book. The
simple diagrams and explanations leave
you in no doubt that you are reading a
pharmacology book, this is a particularly
popular book because of this. This book
does rather jump in at the deep end, which
may mean you require a physiology book if
your knowledge in this area is lacking.
Chapter 4
which will help to initiate bowel
movements
Simvastatin Reduces HDL
cholesterol levels in the blood as
a prevention of atherosclerosis
Streptokinase (thrombolytic) Used
in acute myocardial infarction as
it breaks down the fibrin within
the clot very quickly
Tamoxifen (anti-oestrogen) Used
for those with oestrogen-receptive
breast cancer to help slow the
growth or to prevent recurrence
post-removal
Terbutaline (β2 agonist) A
bronchodilator used as a dry
powder in a metered dose inhaler
to help prevent asthmatic
exacerbations
Tramadol (analgesic) Used to treat
moderate-to-severe pain.
Traditionally classed as an opioid
but it also has a secondary
serotinergic action which
enhances the analgesic properties
Warfarin (anticoagulant) Used to
help prevent deep vein
thrombosis and pulmonary
embolism, stroke, etc. by reducing
the clotting risk. Patients taking
warfarin are expected to have their
clotting rate monitored regularly
Payne, R.A., Donaghy, M., 2010. Payne’s
Handbook of Relaxation
Techniques: A Practical Guide for
Healthcare Professionals. Churchill
Livingstone, Edinburgh.
While not explicitly related to pharmacology,
this is a great book for understanding the
effects of relaxation/stress on the body. A
great synopsis of the sympathetic outflow
and the clinical implications help the reader
to understand the relationship between the
patient and their symptoms.
Other books are, of course, available and
pre-purchase reading/library usage is
recommended.
65
 Chapter
Reflection
Sarah Prenton, Lindsey Dugdill and Linda Hollingworth
INTRODUCTION
Reflection is a process that is acknowledged as being fun­
damental to skilled clinical practice for healthcare profes­
sionals. However, the value and application of reflection
is widely debated. In some instances, reflection is just seen
as the completion of a portfolio submitted at the end of
a period of learning; however, it is argued here that reflec­
tion should be much more – an attitude or approach
that enhances professional development and practice.
This chapter aims to introduce physiotherapy students
and physiotherapists to the concept of reflective practice,
including definitions of reflection and the rationale for
reflection in practice. It then highlights the key processes
and important principles involved in reflection. It con­
cludes by discussing ways to reflect, including tools and
models that can be used to explain and encourage
reflection.
This chapter is built around Salford physiotherapy grad­
uates’ views on reflection and becoming reflective practi­
tioners in the real world. Consequently, the emphasis of
this chapter is on how to successfully start to analyse
practice. Ideally reflective practice should involve an
emotive, as well as technical element; however, the con­
sideration of ‘feelings and emotions’ is also frequently
cited by physiotherapy graduates as a barrier to initial
engagement.
… we’re ‘sciencey’ people, we took a ‘sciencey’
course and so to sit down and write on a piece
of paper about how something made you feel
doesn’t make sense…
Graduate Reflective Group 2010 (Student 5)
… to put an emotional aspect about what I’m
doing, what I’m feeling is not in my makeup…
Graduate Reflective Group 2010 (Student 3)
5 
This chapter aims to engage physiotherapists who are
new to these concepts by giving them a toolkit to begin,
and develop, as reflective practitioners. Becoming a reflec­
tive practitioner is an essential life skill for all physio­
therapists. Skills of reflexivity – being able to think about
and critically analyse experiences and understand their
meaning – is important in becoming more proficient in
practice. Reflecting on day-to-day experiences helps profes­
sionals to ‘think through’ decisions that have been made
with respect to say a particular patient case or work sce­
nario. This is essential in new or novel situations – which
for the student practitioner will be most of day-to-day
practice to begin with.
DEFINING REFLECTION
There are numerous definitions of reflection, a selection
are provided below.
Definition
Reflection is looking at whole scenarios from as
many angles as possible: people, relationships,
situation, place, timing, chronology, causality,
connections and so on, to make situations and
people more comprehensible
(Bolton 2005: 9)
Reflection in the context of learning is a generic
term for those intellectual and affective activities
in which individuals engage to explore their
experiences in order to lead to new understandings
and appreciation.
(Boud et al. 1985: 19)
67
 Tidy’s physiotherapy
Reflection is a form of mental processing – like a form
of thinking – that we use to fulfil a purpose or to achieve
some anticipated outcome. It is applied to relatively com­
plicated or unstructured ideas for which there is not an
obvious solution and is largely based on the further
processing of knowledge, understanding and possibly
emotions that we already possess (Moon 1999).
It is clear from the numerous definitions of reflection
that people develop personal and individual views of what
reflection is; this is influenced by factors such as discipli­
nary background. The differences in terms used, interpre­
tation and perspective can result in confusion; however,
there are clear commonalities and overlap within the work
of different authors on the subject. In its simplest form,
reflective practice is a process of thinking about and ana­
lysing an experience or set of actions. In this case, it would
relate to a work scenario or situation. There are many tools
that can help processes of reflection, such as keeping
reflective logs or diaries, which will be discussed later in
the chapter; this is common practice with many other
disciplines, such as nursing and sports coaching (Knowles
and Telfer 2009).
Knowles and Telfer (2009: 24) make it clear that reflec­
tive practice is not just a process of thinking where you
literally ‘go round in circles’, but a cognitive process
which encompasses ‘deliberate exploration of thoughts,
feelings and evaluations focused on practitioner skills
and outcomes. The outcome of reflection is not always
preparation for change, or action based, but perhaps
confirmation/rejection of a theory or practice skill option’.
This description gives the process of reflection a feeling of
trajectory where the individual undertaking the reflection
ends up in a different place from where they started,
whether through new understanding of practice, new
knowledge or both. This process of moving forward is
crucial in gaining a better understanding of effective prac­
tice. Understanding what is not working well in a service,
process or any practice situation is just as important as
identifying positive practice – it highlights what needs to
change.
For further reading on the topic of reflection and re­­
flective practice see Ghaye (2005), Moon (1999) and
Schon (1983).
Rationale for reflection in practice
Effective reflection should improve understanding of the
positive and negative aspects of practice, and, subse­
quently, should enable more informed decisions to be
made in the future, leading to better quality of life and
health outcomes for the patient. Over time, this enables
practitioners to become expert at what they do. Develop­
ing excellent clinical reasoning (discussed further in the
following section) is one of the fundamental expectations
for health professionals and reflecting on practice can help
to improve this process. Reflective practice is a lifelong
68
skill, as the need to continually update practice is some­
thing all professionals face in their career. Therefore,
becoming a skilled reflective learner early in an individu­
al’s professional career is essential.
As well as developing individual skills and expertise, it
is vital that physiotherapists understand how best to
work together in interprofessional teams (Zwarenstein
and Reeves 2006). Therefore, reflection should not be
just about self and the work context but the wider scope
of team activities. Interprofessional working requires an
understanding of the boundaries or limits within which
any professional both could and should operate (Dugdill
et al. 2009). Reflective practice plays a vital part in
enabling professionals to learn and understand the
impact of their actions. External factors, such as work­
place policy and professional body requirements, as well
as internal factors, such as attitudes, skills, experience
and team dynamics, can all be issues that are useful to
report on.
In time, as the skills of reflective practice develop in an
individual, the value of continuing to utilise reflective
practice skills becomes obvious as they usually lead to
improved clinical work performance and, ultimately, to
better patient outcomes. It is much better if the inherent
value of reflective practice becomes an accepted way of
working for a professional from the early days as a student
and it should be continued as a life-skill forever. If reflec­
tive practice is just seen as a task to be completed for an
assessed piece of work it is unlikely to become a habitual
and valued process that becomes embedded in practice.
One of the biggest challenges faced by tutors of reflective
practice is convincing students of its value in the longer
term. Many physiotherapy graduates reported that initially
they did not see the value in reflective practice:
… you just don’t realise how important it is…
Salford Graduate Reflection Group 2010 (Student 1)
… you are there [University] for physio, so
anything non-clinical, non-anatomy, non-
looking at the hip! – well I can justify why I’m
doing this, doing that, but reflection to me really
was a waste of time…
Salford Graduate Reflection Group 2010 (Student 3)
Until it was an area that required a formal
assessment I considered it to be of less worth
than the other aspects of my course.
Final year reflective assignment 2010 (Salford student)
Looking back I believe I underestimated the
importance of the reflective process and how it
could contribute to my development.
Final year reflective assignment 2010 (Salford student)

The conclusion from these statements is that reflective
practice has to be undertaken to be understood and
valued.
CLINICAL REASONING AND
EVIDENCE-BASED PRACTICE
A common characteristic of students, and even new gradu­
ates, is that they may display knowledge but cannot always
apply it in practice. In other words, they struggle with what
is known as clinical reasoning.
Definition
Clinical reasoning (or practice decision-making) is a
context-dependent way of thinking and decision-making
in professional practice to guide practice actions. It
involves the construction of narratives to make sense of
the multiple factors and interests pertaining to the
current reasoning task. It occurs within a set of problem
spaces informed by the practitioner’s unique frames of
reference, workplace context and practice models, as
well as by the patient’s or client’s contexts.
It utilises core dimensions of practice knowledge,
reasoning and metacognition, and draws on these
capacities in others. Decision-making within clinical
reasoning occurs at micro-, macro- and meta-levels and
may be individually or collaboratively conducted. It
involves metaskills of critical conversations, knowledge
generation, practice model authenticity and reflexivity
(Higgs and Jones 2008: 4).
As it can be seen it is therefore obviously not something
that can come from absorbing.
In order to develop clinical reasoning, novice practition­
ers first need to acquire a large amount of biomedical
knowledge. It is then often assumed that once acquired,
and simply with repeated practice, they will then be able
to make appropriate links between different aspects of that
knowledge. This is usually not the case; hence the difficul­
ties seen in application.
As Higgs and Jones (2008) state, clinical reasoning relies
on the integration of three key processes in order to be
successful (Figure 5.1).
Knowledge: this relates to an individual’s personal
knowledge of anatomy and physiology, and knowledge
of pathological and inflammatory processes. It also
includes knowledge of evidence and how to evaluate it
appropriately. It should also encompass valuing and
considering the patient’s knowledge of their health.
Reflection Chapter 5
Knowledge Meta-cognition Cognition
Figure 5.1  Integration of three key processes.
Cognition: this relates to an individual practitioner’s
ability to analyse data, synthesise information and
develop strategies of inquiry. In other words, their ability
to think through the information you collect and
problem solve.
Meta-cognition: this relates to an individual
practitioner’s ability to review the strategies they are
using, consider what might have influenced/biased/
limited them, compare this experience against previous
ones and generally be critically analytical of their
practice.
This last component, meta-cognition, is considered the
integrative link between the other two areas. Reflecting on
practice takes place within the meta-cognitive domain.
The necessity of this integration is because of the fact
that no situation will be like another: each clinical encoun­
ter will be unique. It is therefore important to consider
all aspects of the experience in order to develop skills
(cognitive and knowledge) for the next time. Failure to
follow through these lines of inquiry will result in poten­
tial errors in the conclusions and plans drawn.
Applying the above concepts to a
real world physiotherapy context,
for example the painful shoulder
A client’s problem could be physical, psychosocial or a
combination of these; it could be derived from a number
of different origins and could be acute, chronic or an acute
flare up of a chronic problem. The first time you are faced
with this diagnosis the conclusions you draw might be
ineffective or incorrect because of either a limitation in
your knowledge base, problem-solving skills or limita­
tions in your interaction with the patient for a variety of
reasons. If you fail to reflect on the conclusions regarding
a diagnosis and/or treatment plan then you are destined
to make them again, even if they are not effectual. Like­
wise, if the conclusions you draw are correct you need to
analyse how you came to them in order to perpetuate this
with future patients. This is about understanding ‘what
works well and why’.
It might, therefore, be assumed that the very first time
you treat a condition your reasoning will be purely knowl­
edge based. However, this is not the case as certain people
69
 Tidy’s physiotherapy
will have previous experiences, have read different sources
of material, and observed other clinicians. It is this indi­
viduality that also requires analysis and reflection after
the experience so that it can be utilised and developed for
the future.
Novice practitioners tend to use what is often known as
hypothetico-deductive clinical reasoning (Jones et al.
2008). This is where hypotheses (initial impressions) are
systematically tested out in order to reach a logical, diag­
nostic conclusion. This requires a significant cognitive
demand, tends to focus primarily on physical impairments
and may still result in the actual reason for presentation
being elusive. By contrast, an expert is said to be someone
who is perceived to be ‘capable of doing the right thing at
the right time’ (Jensen et al. 2008: 123) – their method of
clinical reasoning will be different in that it is based on
pattern recognition (colloquially termed ‘patient mileage’)
with not only large numbers of possible hypotheses con­
sidered but various other components of the individual
patient and context taken into account. These include the
patient motivations, reasoning based on the rapport and
collaboration with the patient, envisioning the future and
considering ethical implications (Jones et al. 2008). While
seemingly more complex, this process actually requires
less cognitive demand at the time of assessment.
The difference between the novice and the expert’s clini­
cal reasoning skills is, in part, because of an increased
depth of knowledge but also how that knowledge is
manipulated. This cannot be achieved through repetitive
practice, but rather practice-analysis (reflection) and the
re-practice (Boshuizen and Schmidt 2008). In other words,
if you do not learn from your experiences you will never
develop expertise. Non-reflective clinicians will have a ten­
dency to only look for, and over-emphasise, certain signs
and symptoms, disregard others which do not concur with
their preconceived ideas and form conclusions which do
not consider the individual; in other words, they are not
patient-centred. This can result in substandard care for that
individual. This occurs most commonly when less experi­
enced practitioners try and ‘mimic’ expert clinical reason­
ing without fully understanding the processes necessary to
truly achieve expertise.
It is interesting to note, however, that to an expert, who
has been reflective, routine clinical practice will actually
be relatively non-reflective unless the situation is novel to
them. In this instance, however, it should be remembered
that their role and responsibilities will be such that
they will have many other activities that they will need
to reflect upon, such as leadership/team-management,
service development and research, which may be deemed
as higher practices.
There can be a perceived tension between the drive
toward developing the scientifically researched evidence
base for physiotherapy practice and the value of profes­
sional knowledge developed through experience. Much
has been written previously on the processes of reflective
70
practice as being part of a continual learning cycle (Ghaye
2005). Students are taught from an evidence base of ‘what
works’, but the literature is often not complete or not
relevant for the working context, so experiential learning
‘from practice’ and evaluation of that practice is required
in order to understand what processes and interventions
work best in order to develop clinical reasoning skills.
National and local guidelines/protocols that are based
on the best available evidence at any time are designed to
ensure consistent high quality care of patients. However,
there can be a tendency, as a clinician, to simply follow
that guidance without questioning. Firstly, in reality clini­
cians need to be critical of the evidence itself as it is of
varying quality. This is why undergraduates are shown
how to evaluate the quality of evidence and this skill
requires continued practice once qualified to ensure the
application of the most appropriate theory to practice.
Secondly, consideration of the evidence/protocol/guide­
line needs to be taken in the context of individual practice
(see below).
Example
Mental practice of upper limb movement
following a stroke
In the Royal College of Physician’s national clinical
guidelines for stroke (Intercollegiate Stroke Working Party
2008:76) ‘Patients should be taught and encouraged to
use mental practice of an activity as an adjunct to
conventional therapy, to improve arm function’.
As a clinician should you therefore assume that you
should be using this with every patient you encounter
who has had a stroke? This recommendation was based
on a single paper and therefore this recommendation
needs to be considered in the context of the quality/
quantity and transferability of the evidence it was based
on, for example sample size, the part of the population
it was conducted on (generalisability), etc. and also
your own knowledge, experience and skills, and,
most importantly, your patient’s needs, goals and
biopsychosocial abilities.
Additionally, as a clinician you need to be critical of
current practice and may be working in a brand new or
extended role (Figure 5.2). In this case, gaps in the litera­
ture base and/or your own experiences of implementing
current practice may generate further questions for ongoing
research. As Dugdill (2009:49) previously stated:
The advancement of a professional role requires
that profession to be committed to the continual
‘development of thinking’ – both generating and
testing new knowledge – in order to improve the

Reflective practice/ Clinical reasoning EBP/knowledge/
experience/practice theory
delivery, and hence impact, of the role.
Sometimes professional practice may involve
trying new things, being innovative and
challenging the boundaries of existing practice.
This may be especially relevant when a client
fails to respond to a tried-and-tested approach
and the practitioner feels the need to try
something different.
Therefore, reflective practice should be seen as a central
process for both continuing professional development
(CPD) and evidence-based approaches, both of which are
fundamental to high quality professional practice. Without
all these described processes being in play you will not be
able to achieve your full potential as a physiotherapist
remembering that ‘clinical reasoning and clinical practice
expertise is a journey, an aspiration and a commitment to
achieving the best practice that one can provide’ (Higgs and
Jones 2008: 9).
For further reading on these topics please refer to Higgs
et al. (2008).
REQUIREMENTS FOR REFLECTIVE
PRACTICE
Becoming an effective reflective practitioner is now an
expected requirement of all health professionals in order
to drive continued improvement in practice and allow the
interface between theory and practice to be constantly
analysed by the professional.
In order to practice as a physiotherapist within the
UK, practitioners must hold registration with the Health
and Care Professions Council (HCPC). HCPC standards
ensure that all health professionals must continue to
develop their knowledge and skills in order to maintain
registration. These standards (HCPC 2006) state that reg­
istrants must:
1. maintain a continuous, up-to-date and accurate
record of their CPD activities;
2. demonstrate that their CPD activities are a mixture
of learning activities relevant to current or future
practice;
3. seek to ensure that their CPD has contributed to the
quality of their practice and service delivery;
4. seek to ensure that their CPD benefits the service user;
Reflection Chapter 5
Figure 5.2  The interface between evidence-based
practice (EBP) and reflective practice.
5. present a written profile containing evidence of their
CPD upon request.
The HCPC states that physiotherapists must participate
in ‘a wide range of learning activities through which
health professionals maintain and develop throughout
their career to ensure that they retain their capacity to
practise safely, effectively and legally within their evolving
scope of practice’ (AHP Project 2003: 9). The use of reflec­
tion is identified as one of the key activities, especially in
learning from practice in the workplace. The recognition
of learning requires a process of reflection and evaluation
and it is this process that can prove difficult. Yet, reflecting
on workplace practice after it has occurred is integral to
workplace learning. It enables subconscious thought to
be critically examined, evaluated and articulated. It also
allows theories from formal programmes of study to be
connected with and integrated into practice.
The physiotherapy graduates discussed how, as well as
reflective practice being a mechanism to consider practice,
collecting evidence of the process was often the only evi­
dence of learning and achievements. It’s a way of ‘monitor­
ing you along a timeline’ (Student 3) and ‘a way of
fulfilling your portfolio requirements’ (Student 3).
USE OF REFLECTION AS A FORM  
OF ASSESSMENT
Undergraduate and postgraduate physiotherapy pro­
grammes commonly use reflection as a component of
assessment; this can be formal, summative assessment or
more informal, formative assessment. Because the work is
being produced for an external reader who will make a
judgement about the ‘quality’ of that reflection and often
give it a mark, the nature and content of the reflection will,
inevitably, be altered. There is much debate within the
literature regarding the effects of assessment on the
development of honest and truthful reflection. A student,
knowing the reflective essay or portfolio is to be assessed,
will frame the written response to make them (and their
practice/expertise) appear in a positive light; hence, the
‘messy reality’ and mistakes of practice may be lost from
the reflective account. Some argue that reflection and
assessment are incompatible (Hargreaves 2004); however,
many practitioners will admit that without the external
motivation that assessment provides, combined with the
formal training and feedback received through the process,
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 Tidy’s physiotherapy
they would not have devoted the time and energy to devel­
oping the skill. Even the use of ‘I’ within academic writing
can be seen as controversial in academic settings; tradi­
tional academic assignments require writing in the third
person and discourage the expression of personal or
unsubstantiated comment (Lindsay et al. 2010). The fol­
lowing quotes from physiotherapy students and graduates
highlight the debate and motivations for undertaking
assessed reflection:
… when being formally assessed I spent more
time asking myself questions of my reflective
practice and reflective writing style. I have also
discovered that for me to be motivated to do
something I need to have some form of praise to
encourage me to do it…
Final year reflective assignment (Salford student 2010)
I may have adapted my writing because I knew
that someone would read it and I was
uncomfortable with talking about my feelings
and this would have impacted on the depth of
my analysis, this is supported within the
literature…
Final year reflective assignment (Salford student 2010)
Some literature suggests that the descriptive
nature of a reflection can be the result of its
involvement in an assessment process because
the reflector holds back on emotions, opinions
and is less open and honest as someone will be
reading it (Hargreaves 2004). Personally I do
not believe this applies to me…
Final year reflective assignment (Salford student 2010)
Perhaps the answer is to almost ‘force’ me to use
written reflection by making the amount
completed potentially detrimental to attaining
marks. I am then more accountable.
Final year reflective assignment (Salford student 2010)
… if I’m just going to write it for me to stick
in my file it’s just going to be a box ticking
exercise…
Salford Graduate Reflective Group 2010 (Student 5)
… it [assessment] can change what you write…
Salford Graduate Reflective Group 2010 (Student 1)
Reflection used as assessment may bring additional
requirements, such as links to portfolio evidence or to the
research literature within a particular area. As a student,
72
you may be asked to consider your reflection on practice
within a theoretical context, for example: ‘In your manage­
ment of the patient reflect on the intervention techniques
you chose to use and why? Please refer to evidence
from the literature to justify your choice of treatment or
intervention’.
It is important to remember that the sharing of reflec­
tion is within the practitioner’s control. Ultimately, it is
the individual’s decision which aspects of their reflection
are private and which are appropriate for sharing with
another person, whether that is a mentor, manager or
academic tutor. For instance, the reflective diary of a prac­
titioner is normally considered private. The student can
then use it as the ‘aide memoire’ to help them think back
over a case or work scenario that they are analysing for
their coursework.
I would keep a diary every day on placement …
I would write up a full reflective piece for my
visiting tutor and the others about 18 months
later based on my diary…
Salford Graduate Reflective Group 2010 (Student 2)
PROCESSES OF REFLECTION: USING
REFLECTION IN PRACTICE
Definition
Reflection on/following action
Taking a step back from an experience or activity in
time and space, using questioning to develop a better
understanding of a situation or area of practice
(CSP 2005).
Reflection following action/
reflection on action (Schon 1983)
This is the reviewing of an experience or event at some
point after it has occurred in order to evaluate and under­
stand it to a greater degree. It allows physiotherapists to
explore and analyse their actions in order to investigate
and articulate how they completed the task and why they
did it in the way they did. There is an aim to make the
tacit professional knowledge more open and explicit so
that practice can be challenged and performance improved.
Various models have been developed to assist practi­
tioners in developing reflection on action. These generally
provide encouragement to follow a cycle of reflection and
provide prompt questions to encourage deeper explora­
tion; these are introduced later in the chapter.

Example
A standardised physiotherapy treatment protocol is being
used for patients following an orthopaedic procedure as
a result of the failure to progress for a number of
patients. Reflection may be used to consider the
following questions:
• What happened with the cases concerned?
• Was the protocol implemented as planned? Why/why
not?
• What other factors (internal or external) may have
influenced the outcomes?
• Can common features or patterns be identified?
• Can reviewing the literature in the area assist?
• Is the protocol up to date?
• Is the protocol still considered best practice?
• How does our protocol/outcomes compare with other
similar departments?
• How does the implementation of the treatment
compare to the research/other similar departments
• What other considerations/constraints need to be
considered before suggesting/implementing change.
This exploration, which would ideally be done as a
team, would then be used as a basis for planning.
Reflection following/reflection on action is useful for
developing skills where incremental improvement is pos­
sible; however, it is also necessary to reflect during activity
and before it takes place.
Definition
Reflection in action
Professionals are able to think what they are doing
while they are doing it.
(CSP 2005)
Example
A physiotherapist treating a patient who reacts in an
unexpected way to an intervention is able to consider
the factors influencing the patient’s reaction, explore a
range of alternative approaches, and implement and
evaluate them without interrupting the flow of
treatment.
Or
A physiotherapist who receives particular pieces of
information during a subjective history may adapt the
components of the objective examination or change the
order of their assessment.
Reflection Chapter 5
Reflection during action/reflection
in action
Experienced physiotherapists (skilled or expert practition­
ers) have the ability to ‘read’ experiences and adapt their
intervention or behaviour during that intervention as
opposed to needing to evaluate the experience after it
occurs. This is sometimes known as reflection in action
(Schon 1983). This can be regarded as more than
responding intuitively, as it should involve some con­
scious consideration of what is happening, how effective
the behaviour is and whether there might be more ap­­
propriate alternatives (Wilson 2008). This skill of ‘think­
ing on your feet’ can be taken for granted by experienced
physiotherapists but can represent a challenge for the
novice practitioner.
Reflection before action/reflection
on the future
Definition
Reflecting on the future
The act or process of reflecting on desirable and
possible futures with the purpose of evaluating
them as well as considering strategies intended to
achieve the objective(s).
(Wilson 2008: 180)
Wilson (2008) discusses the importance of considering
reflection before action and proposes that this natural part
of human thought processes has been neglected in the
literature on reflective practice. He argues that profession­
als reflect after and during action but ‘should systematically
reflect on the future’ (p. 178) (Figure 5.3).
Reflecting on what might be is one of the most
powerful mental tools we have at our disposal.
Without this ability to speculate about what
might be, we would be constrained within the
present or the past. If we lack the ability to
reflect on the future there could be no plans, no
hopes, no aspirations, no wants, no dreams and
no desires.
(Wilson 2008: 180)
Reflecting with a supervisor
Participation in clinical supervision is regarded as a vital
aspect of professional development.
73
 Tidy’s physiotherapy

Figure 5.3  The process of reflection in treatment of

Reflection before action Description a patient.
Reflection in action
Planning of a treatment;
Adaptation of the
what techniques, what
treatment based on
order, where will it be
the patient's status,
performed, what is the
their reaction, the
desired outcome, what
environment, equipment,
might go wrong, what
instant feedback etc.
preparation is required etc.

Reflection on action
Thoughtful analysis and
evaluation of the
treatment at a later point;
possibly utilising feedback,
external resources
(other people, research)

Supervisors, therefore, have a huge impact on how as a confidential ‘sounding board’, especially for issues
novice practitioners view reflective practice. which would not be mentioned in front of a senior col­
league (see issue of disclosure later).
It very much depends on the whole attitude of
educators…
Salford Graduate Reflective Group 2010 (Student 2)
Example

… if they (supervisors) can’t be bothered,
I can’t be bothered…
Salford Graduate Reflective Group 2010 (Student 3)
Supervision is a mechanism that should allow the
learner time with a colleague (usually more experienced)
to assist in the development of professional skills. The
process can be seen as similar in nature to mentorship
(Fowler and Chevannes, 1998) with the ideal characteris­
tics of the mentor including feedback-giver, eye-opener,
challenger and idea bouncer (Darling 1984). Fowler and
Chevannes (1998) suggest that while there is a high degree
of compatibility between clinical supervision and reflec­
tive practice, there may be some practitioners, especially
those at a novice level, for whom the reflective element of
the process may be less useful and even detrimental; their
recommendation being that the supervision process needs
to be tailored to the needs of the individual. Findings from
research into clinical supervision within the physiotherapy
profession ‘highlighted the value that Physiotherapists
placed on having formal ‘time out’ to reflect on their prac­
tice. However, clinical supervision was found to fulfil a
variety of functions at different times, being tailored to
meet individual needs.’ (Clouder and Sellars 2004: 263).
Ideally, a clinical mentor should be someone with
expertise of their own to bring to the discussion (e.g.
senior professional colleague). However, in addition, it is
often useful to have a neutral colleague/friend who can act
Scenario: Consider a patient you have recently treated
for a musculoskeletal problem.
1. Briefly describe the problem and reflect on the
process of diagnosis and treatment.
A. What did you say and why?
B. What skills did you employ and why?
C. What treatment or intervention did you prescribe
(if any) and why?
2. How did your handling of the patient impact health
outcomes?
3. Were you happy with your handling of this case?
4. What would you do differently in future?
Reflection requires honesty from the reflector and it could
be argued that it should be built on solid evidence of what
has actually happened. However, this can cause dilemmas
for the reflector, for example being able to speak about
mistakes or processes that have not gone well. There may
be circumstances in which it would be very risky to do this,
for example disclosing a serious professional error in front
of a senior colleague or educator (or during a piece of
assessed coursework). You may not want to disclose some
issues during a team de-brief session, for instance, if it
might effect a future promotion opportunity. The notion
of a critical friend as mentor should sit outside the
judgemental/assessment process. The mentor has become
recognised as being very important in the reflective

74

practice process. A critical friend is a trusted person who
asks provocative questions and can:
observe, listen and learn;
demonstrate positive regard for the learner;
help identify issues and explore alternatives;
offer sources of evidence/expertise;
work collaboratively;
encourage the learner to explore possibilities;
offer a thoughtful critical perspective.
(Stroobants 2004)
In order to be able to disclose the ‘truth’ during reflec­
tion a safe environment needs to be provided in which
that reflection can take place, i.e. there needs to be an
established mentor-reflector relationship within which the
reflector can trust the mentor that absolute confidentiality
will be assured, whatever is disclosed. Trust in this context
is all about having a mutual exchange (reciprocity) and
developing a relationship where the trust increases incre­
mentally over time: different types of trust relationships
have previously been identified as being important in
reflective practice.
Contractual Trust (trust of character), keeping
agreements, honouring intentions;
Communication Trust (trust of disclosure)
telling the truth, admitting mistakes, give and
receive constructive feedback;
Competence Trust (trust of capability) how
capable are participants of trust.
(Reina and Reina 2006)
It should be made clear from the start what the bounda­
ries of the mentor relationship are; there may be issues
of disclosure that would require disclosure whatever
the relationship, for example criminal acts or patient
cruelty/abuse. In order to become a skilled practitioner,
the safe environment in which reflective practice takes
place should be non-judgemental in order to allow/
promote the disclosure of all issues in order for the
reflector to be able to move forward and learn from prac­
tice, however novice they are.
This safe environment needs to be negotiated at the
beginning of your reflective practice journey and finding
a skilled mentor who has the skills to help you to reflect
well will be crucial to success. An example of a ‘confes­
sional’ recounted as part of an evaluation study of Health
Trainers in Salford (Dugdill et al. 2009) serves to illustrate
the importance of the ‘safe’ environment for de-briefing
purposes, especially for novice professionals/practitioners.
The following quote was taken from a reflective interview
between a health trainer and the evaluator, and highlights
how professionals at the chalk face may have to deal with
some very difficult issues when dealing with the public.
Reflection Chapter 5
It was scary. I had two referrals from people who
said they wanted to kill themselves … I was quite
emotional about it. There was a time when I was
thinking this isn’t the right job for me … I might
do more harm than good.
(Dugdill et al. 2009: 125)
The health trainer went on to say that they had
been uncertain what to do and how to de-brief following
this incident. Ideally, reflection and de-briefing can
become integral processes for professionals and are essen­
tial in situations, such as the above scenario, where a
novice professional may need guidance and support
immediately.
There are a range of different types of mentorship/
supervision that can be useful to a reflector. One or more
of these relationships can be established to support the
reflector at any one time (Richmond 2009):
• line management – performance, competence,
outcome driven;
• group supervision – interprofessional team-working
situation;
• peer support – interprofessional team-working
situation;
• individual supervision – supervisor leads;
• individual mentoring.
It is important to understand the power differentials
that may exist between the reflector and each of these dif­
ferent types of supervision situation or mentorship rela­
tionship, as this will effect quality of reflective practice.
IMPORTANT PRINCIPLES  
OF REFLECTIVE PRACTICE
There are certain features to reflective practice that are
integral to its success.
Closing the loop
This is about seeing reflection as a process not as a product.
Reflective practice is about analysing your practice and also
ensuring that you draw conclusions as to what you have
learnt about a specific treatment, assessment tool and
experience, but also about yourself as a physiotherapy
practitioner.
Planning
Whatever the experience you have been through, be it a
single assessment or a series of treatments with a patient,
you are never going to have exactly the same experi­
ence again. As such, the reflection you complete should
75
 Tidy’s physiotherapy
Tip
Sometimes identifying an aspect of your practice that
you would like to improve and using this as a focus for
your reflection can help you be more specific when
identifying outcomes. For example, if you feel your
clinical reasoning during patient assessment is an area
you would like to improve you can focus your thoughts
towards this aspect rather than considering other
aspects, such as communication.
result in a number of plans for how you will apply what
you have learnt about yourself and physiotherapy in other
situations. We have all been in situations where we have
left a situation and thought ‘I said I wasn’t going to do
that again!’ or ‘I must remember to do that in that way
again’. In other words, we have made the same mistake/
delivered a less than ideal treatment twice (or more!) or
done something that worked well (by accident!). The idea
is that if you make plans you follow them in order to be
mindful and continually developing practitioners. You
cannot always ensure you can implement this because
sometimes there may be insufficient time between experi­
ences or an experience could be completely unexpected.
In addition, the plans you make as a result of reflection
might not be ‘right’. After all, you can only base future
plans on the current experiences so the conclusions you
draw might not work as you expect. However, this reiter­
ates the purpose of reflection, which is not about getting
it ‘right’ every time but about developing new skills, atti­
tudes, approaches and techniques honed by each experi­
ence. This is a process that will continue throughout your
careers.
… you will always be a work in progress, you
will never be the finished article…
Salford Graduate Reflective Group 2010 (Student 5)
… qualifying is like learning to drive, passing
your test is only the beginning…
Salford Graduate Reflective Group 2010 (Student 5)
Do not worry if you fail to make meaningful plans
but when you repeat either an unsuccessful practice
or fail to repeat a successful approach revisit previous
reflections and use them to help inform your ongoing
plans.
Appropriate timing
In terms of reflecting on action (Schon 1983) there is not
a specific timescale; however, it should be done ideally
76
Tip
I think I assumed that the content of my reflections
would inherently bring about a change in my
behaviour and facilitate my development as a
[reflective practitioner]…
Final year reflective assignment (Salford student 2010)
If you are starting in a new clinical area review older,
written reflections to remind yourself what you planned
to do and incorporate it into your learning agreement/
contract/development plan or personal development
plan.
within a timeframe where you can remember the details
of what happened and potentially how you felt, as this
then allows you to draw more from it. That being said,
benefit can also be seen from reflecting immediately after
an event and then reconsidering it again a short time later
with the added perspective of time.
Example
A patient falls while you are with them; this has never
happened to you before. Your initial reflection will
probably be very focussed on your emotions and on
details you would want to change. Therefore, the
likelihood is it will be negative. A few days later
the reflection might be more balanced and you
are able to see more of the positives/be more
objective and therefore produce more realistic
planning strategies.
Certain experiences will tend to make you reflect more
than others and over longer periods of time. However,
choosing to reflect on an experience weeks or even months
after it has occurred dilutes its efficacy. It is probable
you have already had further experiences that have had
an influence and will feel very differently about it. You
may have also perpetuated errors you made initially. As
a result, reflections approached in this way tend to be
‘sanitised’ versions, lacking depth and relevance to the
individual.
Others' perspectives
Certainly, some of the models of reflection (see later in
chapter) ask you to consider the experiences from the
perspectives of other people. If you are using a different
 Reflection Chapter 5

method (see later in chapter) you may still want to con­
sider these individuals. In addition, you might want to
consider your decisions/choices in the context of literature/
protocols as another perspective.
Knowing yourself
In order to challenge yourself as you progress in practice
you need to evaluate yourself now. This may involve using
documentation such as SWOT (strengths–weaknesses–
opportunities–threats) analyses, learning styles question­
naires, team role questionnaires or personality tests. It
might also incorporate evaluation of your previous experi­
ence and background. Reviewing these types of aspects on
a regular basis will enhance the depth of your reflective
practice.
What to reflect on
Students or those new to utilising reflection as a develop­
mental tool sometimes complain that ‘nothing significant
happened’. In reality, this often translates into ‘nothing
bad happened’ or ‘nothing different happened’. This may
arise from the term ‘Critical Incident Reports’, which can
be incorrectly interpreted as meaning a dramatic, unusual,
significant and usually negative experience. While these
experiences do happen and can be usefully harnessed, it
is at least as useful to examine the more routine and
mundane experiences that are more frequently encoun­
tered (Table 5.1). Close scrutiny of those activities which
are taken for granted can lead to more meaningful and
applicable insights into everyday practice (Donaghy and
Morrs 2007).

Table 5.1  Ideas for reflective activity

Experience Aspect Evaluations of…

Interaction with a patient Communication skills • Interview technique

• Motivation skills
• Use of counselling techniques
• Giving instruction
• Reading the patient's non-verbal
communication (NVC)
Assessment skills • Ability to plan subjective/objective
• Clinical reasoning/diagnostic skill
• Manual technique/skill development
• Accuracy of application
• Knowledge of assessment techniques
• Time management
Treatment skills • Manual technique/skill development
• Accuracy of application
• Knowledge of treatment approaches

Interaction with the team Clinical Educator • Negotiating learning activity

Other students
Liaison with other professionals
• Developing a learning relationship
• Understanding expectations
• Managing feedback on performance
• Reviewing documentation
• Managing disagreement or conflict
• Negotiating roles/workload
• Team working/leadership skills
• Receiving information
• Providing information
• Differences in approach/role
• Interaction in team meetings

Attending formal training Delivery of content • Self-assessment of understanding/level

of learning
• Application to own practice
• Relevance/quality of the training
• Challenge and questioning of ‘received wisdom’
Assessment • Preparation for assessment tasks
• Performance in assessment

77
 Tidy’s physiotherapy
As well as reflecting on different issues during practice,
professionals may also reflect in different ways depending
on the purpose of that reflective process, for example a
reflective record might be different if it is for HCPC
re-registration as opposed to learning about personal
development following an incident with a patient. Choos­
ing the best approach can include consideration of issues
such as individual learning preferences, the clinical area
or the nature of the experience; however, the purpose of
the output is possibly the most significant factor: Is the
reflection to demonstrate academic ability? Is it for
personal catharsis? Is it for advancing understanding or
developing reasoning, or to demonstrate achievement for
promotion? Experimenting with different formats and
models of reflection allows the practitioner to develop a
‘tool box’ from which they can select the most effective
method for any given set of circumstances.
WAYS TO REFLECT
Verbal reflection
The power and potential of dialogical reflection to
develop practice has been recognised (Clouder 2000).
Verbal reflection, sometimes also referred to as dialogical
reflection, is normally where two or more people engage
in verbal discussion about a single experience, a patient,
a pathology or a technique/approach. Commonly, this
occurs as a 1 : 1 discussion between more and less expe­
rienced clinicians. For example, an educator and their
student, tutor and student, or a band 7 and band 5 (see
’Reflecting with a supervisor’ in the previous section).
The key to its success is having the other person ques­
tion you and facilitate you in drawing conclusions and
making future plans. At a novice level this may involve
question and answer sessions, feedback on techniques
and more of an informal ‘chat’. It may also incorporate
the more experienced clinician sharing their expertise
with you and even include practising techniques or role-
play. As you progress as a clinician, these interactions
may be more focussed on challenging your assumptions,
examining the theory, considering alternative approaches,
or comparing approaches and the reasons for them.
The facilitator might find using models of reflection, sets
of notes or lists of questions useful when they first
start with this process to ensure a reflective cycle is
followed.
In terms of producing evidence of dialogical reflection,
any written format can be used (discussed later). It may
be that the reflector makes notes during the discussion,
but, likewise, it could be the facilitator. An alternative to
a written record of dialogical reflection is to use an audio
device such as a Dictaphone or electronic voice recorder
when the discussion is going on. In a study to evaluate the
78
use of a framework to facilitate reflection in physiotherapy
students ‘the majority of students felt that the structured
taped interview was the most effective stage of the frame­
work in stimulating reflective thought…several said that
the real value of this step was the opportunity to play and
replay the tape, listening and thinking about their own
responses’ (Donaghy and Morrs 2007: 90). Another option
might be to videotape an actual intervention and use this
as the basis for the verbal reflection. Again, this provides
the opportunity to revisit the experience and analyse it
further.
Graphical (mindmaps, spider
diagrams, concept maps)
Many people have a preference for learning from visual
stimuli; using a more diagrammatic method of document­
ing thought processes can be a useful activity. This less
formal document can be particularly useful for compli­
cated experiences where there is a need to consider multi­
ple possibilities or for situations where it is difficult to
identify where something went right or wrong.
Using a diagram can be a quick way of getting ideas
down on paper and, as such, is well suited as a starting
point for shared (verbal) reflection. For students or physi­
otherapists who find logic, sequencing and short-term
memory challenging, these can be useful tools, allowing
all ideas and possibilities to be scribbled down and then
significant features, links and patterns to be identified
more thoughtfully. Explaining your diagram to another
person can also be a helpful starting point for a reflective
discussion with a mentor.
Reflective diary
As mentioned earlier on in the chapter, reflective diaries
can be used. A reflective log can be for self-analysis only.
Sometimes keeping an audio diary (speaking memo notes
into a digital voice recorder, for example) can be a quick
and useful tool for self-reflection. This audio diary can be
played back in private. It is good practice to ensure you
debrief with a mentor, however, so do not rely on these
self-reflective processes, as one of the crucial elements of
reflection is challenging current ideology and practice.
Therefore you need to expose your ideas to external ques­
tioning either in a formal (senior colleague) or informal
(mentor) setting.
Prose/free writing
This builds on the idea of a diary but tends to be based
on a single incident where the individual wants to explore
it in a greater depth. It simply involves writing down your
‘internal dialogue’ (what you are thinking). There is a risk
of this evolving into a story rather than being reflective in
 Reflection Chapter 5

nature; however, if you are clear about what you want to
gain from the process it can be very cathartic, particularly
if you have encountered a catastrophic event, and can help
you to think more objectively about the details of what
occurred.
Example
A patient who was wrongly diagnosed as not having a
hip fracture that has subsequently been mobilised over a
weekend and you review on the Monday. The reflection
might want to consider the other people involved
perspectives and your role within the multi-disciplinary
team.
Using models of reflection
I think about reflective practice in the same way
that I think about swimming; I feel that if my
technique were better, if I could manage to get my
breathing right and my leg moving the right
direction, I would find it easier, put less effort in
and would enjoy being able to move through the
water sleekly and efficiently. In reality I have
realised the only way to achieve this is with lots of
practice, a good coach and a great deal of
splashing…
Extract from a student diary
Many models and frameworks for reflective practice have
been developed to assist practitioners (especially novice
ones) in understanding the concepts and processes
involved. It can be argued that the slavish use of models
is stifling and results in limiting the scope of free and
inventive thinking (Johns 2005), which is why this element
of the chapter has been left to the end. Many practitioners
do find these models, and the prompts to thinking that
they provide, helpful in developing a reflective thought
process. Ideally, experimentation and practice will lead to
an effective individual approach to reflective practice.
Kolb
One of the most often cited models is that of Kolb’s learn­
ing cycle (Kolb 1984). He argues for a relationship be­­
tween thinking and experience, and views learning from
experience as a cycle involving action and reflection, theory
and practice. As a practitioner you can use this cycle to:
• reflect on an experience from practice, drawing on
previous, linked experiences;
• consider how the experience is informed and
supported by earlier and current practice theories and
evidence-based practice from the literature (gained at
university, at study days, from reading research);
• consider what conclusions you draw from your
reflections and how they link with these other theories;
• consider how the conclusions you have drawn
should be used to affect future practice and plan
how you will introduce these into practice;
• start the cycle again by undertaking a further review
of similar experiences incorporating the changes at a
later stage.
The learning process is continuous in a systematic cycle of
action, analysis and review (Figure 5.4).

Figure 5.4  Kolb’s learning cycle (Kolb 1984).

Concrete Experience
Active Experimentation
Concerned with something
Concerned with trying out
that has happened to you
the new ideas as a result of
or that you have done.
the learning from earlier
Concerned with adopting
experience and reflection
your new ideas into practice

Abstract Conceptualisation
Reflective
Concerned with developing
Concerned with reviewing
an understanding of what
the event or experience
happened by seeking more
in your mind and exploring
information and forming
what you did and how you,
new ideas about ways of
and others felt about it
doing things in the future

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 Tidy’s physiotherapy

Figure 5.5  Gibb’s model of reflection (Gibbs 1988).

Description
What happened?

Action plan Feelings

If it arose again what What were you thinking
would you do? and feeling?

Conclusion Evaluation
What else could What was good and bad
you have done? about the experience?

Analysis
What sense can you
make of the situation?

Gibbs
Gibbs’ model (Figure 5.5) provides a fairly simple cycle,
starting with a description of an event or experience, So what?
What?
working through stages of evaluation and analysis, and (Theory – and
(Descriptive level
concluding with planning for future action. knowledge – building
of reflection)
level of reflection)
Johns
The model of reflection developed by Christopher Johns
(1994; Box 5.1) provides a set of questions or cues which Now what?
help the practitioner work through a reflective process to (Action orientated
consider the issues from a variety of perspectives, and to (reflexive) level
try to understand and learn from the experience. of reflection)

Figure 5.6  Rolfe's model.

Rolfe
Rolfe et al. (2001) propose a framework that uses Borton’s
developmental model. The questions ‘What?’, ‘So what?’
and ‘Now what?’ can stimulate reflection from novice to
advanced levels (Figure 5.6; Box 5.2).
Your choice of reflective method(s) depends entirely on
you as an individual and the experience(s) you want to CONCLUSION
reflect on. In the Salford Graduate Reflective Group,
student 5 said ‘I would prefer just a prosey style’, student In summary, this chapter has outlined the rationale and
2 wanted a few prompts, whereas student 1 felt that ‘more important principles of reflective practice and has
questions to help me’. What is important is that you given ideas as to how to engage with reflective practice
explore different methods in order to determine which successfully. It is an essential professional skill for all
you find the most useful. physiotherapists.

80
 Reflection Chapter 5

Box 5.1  Johns‘ (1994) Model of Reflection Box 5.2  Rolfe et al. (2001) Model of Reflection

Description What …
Write a description of the experience … is the problem/difficulty/ reason for being stuck/reason
What are the key issues within this description that I for feeling bad/reason we don’t get on/etc., etc.?
need to pay attention to? … was my role in the situation?
… was I trying to achieve?
Reflection
… actions did I take?
What was I trying to achieve?
… was the response of others?
Why did I act as I did?
… were the consequences
What are the consequences of my actions
• for the patient?
• for the patient and family?
• for myself?
• for myself?
• for others?
• for people I work with?
… feelings did it evoke
How did I feel about this experience when it was
• in the patient?
happening?
• in myself?
How did the patient feel about it?
• in others?
How do I know how the patient felt about it?
… was good/bad about the experience?
Influencing factors
What internal factors influenced my decision-making and So what …
actions? …does this tell me/teach me/imply/mean about me/my
What external factors influenced my decision-making and patient/others/our relationship/my patient’s care/the
actions? model of care I am using/my attitudes/my patient’s
attitudes/etc., etc.?
What sources of knowledge did or should have
influenced my decision-making and actions? … was going through my mind as I acted?
… did I base my actions on?
Alternative strategies … other knowledge can I bring to the situation?
Could I have dealt with the situation better? • experiential
What other choices did I have? • personal
What would be the consequences of these other • scientific
choices? … could/should I have done to make it better?
Learning … is my new understanding of the situation?
… broader issues arise from the situation?
How can I make sense of this experience in light of past
experience and future practice?
How do I now feel about this experience? Now what …
… do I need to do in order to make things better/stop
Have I taken effective action to support myself and
being stuck/improve my patient’s care/resolve the
others as a result of this experience?
situation/feel better/get on better/etc., etc.?
How has this experience changed my way of knowing in
… broader issues need to be considered if this action is
practice?
to be successful?
(Johns 1994) … might be the consequences of this action?

ACKNOWLEDGEMENTS

The editor would like to thank University of Salford graduates and students for their invaluable reflections. Without
these we would cease to evolve as a profession.

81
 Tidy’s physiotherapy
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 Chapter
Management of respiratory diseases
Stephanie Enright and Fiona M. Schreuder
Note
Other relevant information such as the active cycle of
breathing technique (ACBT) and basic respiratory
anatomy and physiology of the lungs can be found in
Chapter 9.
INTRODUCTION
Diseases of the respiratory system are a major cause of
illness worldwide and are increasingly important as a
cause of mortality and morbidity (WHO 2004). In the
UK they are the most common reason for consulting a
general practitioner (GP) (Yelin et al. 2006) and a recent
report on the ‘Burden of Lung Disease’ suggests that respi-
ratory disease is second only to cardiovascular disease
as a major cause of morbidity and mortality in the UK
(BTS 2006a).
Respiratory diseases encompass a range of diseases
which affect the airways and other structures of the lungs,
and although they are characterised by respiratory symp-
toms, it has become increasingly evident that chronic
pulmonary diseases are associated with a range of non-
pulmonary effects (Sinden and Stockley 2010; Decramer
et al. 2012). In terms of the respiratory manifestations of
respiratory disease, however, they can be divided broadly
into obstructive and restrictive types – although most
patients have elements of both.
1. Obstructive diseases include conditions in which there
is a resistance to airflow, either through reversible
factors such as bronchospasm or inflammation, or
6 
through irreversible factors such as airway fibrosis or
loss of elastic recoil owing to damage to the airways
and the alveoli.
2. Restrictive disorders are characterised by reduced lung
compliance leading to the loss of lung volume,
which may be caused by disease affecting the lungs,
pleura, chest wall or neuromuscular mechanisms.
These diseases are therefore different from the
obstructive diseases in their pure form, although
mixed restrictive and obstructive conditions can
occur.
Obstructive diseases are by far the most common and
have major implications for patients and the economic
burden on healthcare, as they require many years of
medical intervention (Johnson et al. 2007). Therefore,
their pathophysiology and treatment will be discussed
initially in some detail. They are:
• chronic obstructive pulmonary disease (COPD);
• chronic bronchitis;
• emphysema;
• asthma;
• bronchiectasis;
• cystic fibrosis.
As the changing pattern of respiratory disease has
resulted in opportunistic pneumonias, which are a
common presentation in patients with AIDS, the restric-
tive disorders and their management will then be consid-
ered. They are:
• pneumonia;
• pleurisy;
• pleural effusion;
• pneumothorax;
• acute respiratory distress syndrome (ARDS);
• fibrosing alveolitis.
83
 Tidy’s physiotherapy
Finally, there are other lung disorders that fit into
neither of the first two categories but need to be included
because of their prevalence within the community or hos-
pital environment. They are:
• lung abscess;
• pulmonary tuberculosis;
• bronchial and lung tumours;
• respiratory failure (including respiratory failure
secondary to neuromuscular disease).
CHRONIC OBSTRUCTIVE PULMONARY
DISEASE: BASIC ISSUES
Chronic obstructive pulmonary disease (COPD) is an ill-
defined term that is often applied to patients who have a
combination of chronic bronchitis and emphysema,
which frequently occur together (and may also include
asthma). In the majority of cases, chronic bronchitis is the
major cause of obstruction, but in some cases emphysema
is predominant. There are many patients who report short-
ness of breath, increasing in severity over several years and,
on examination, are found to have a chronic cough, an
overinflated chest and poor exercise tolerance. It is often
difficult to assess clinically to what extent these patients
have chronic bronchitis or emphysema, or a mixture of
these. Patients may also present with a more episodic form
of disease, which is a characteristic of an asthmatic com-
ponent. Therefore, ‘chronic obstructive pulmonary disease’
is a convenient term, which encompasses one or all of
these components. Although COPD is an umbrella term
for a combination of these clinical entities, both the aetiol-
ogy and patho­logical features of chronic bronchitis and
emphysema will be considered initially before a discus-
sion of the clinical features and management of COPD is
discussed in more detail.
Key point
In patients with COPD, chronic bronchitis, emphysema
and asthma often coexist; the disease is progressive and
characterised by acute exacerbations. It is not usually
diagnosed until irreversible damage has occurred. As well
as the respiratory component of COPD, it is also
associated with a range of coexisting extrapulmonary
effects.
Although historically COPD was considered as a disease
of the lungs characterised by irreversible airflow obstruc-
tion, there is now increasing evidence that it presents
with other associated comorbidities such as skeletal
muscle dysfunction, cardiovascular disease, osteoporosis
and diabetes (Sinden and Stockley 2010; Decramer
84
et al. 2012). Therefore, because there is increasing recogni-
tion of the presence and impact of non-pulmonary mani-
festations, this has led to the now established international
definition from the Global Initiative for Obstructive Lung
Disease (GOLD).
Key point
Chronic obstructive pulmonary disease (COPD) is a
preventable and treatable disease with some significant
extrapulmonary effects that may contribute to the
severity in individual patients. Its pulmonary component
is characterised by airflow limitation that is not fully
reversible. The airflow limitation is usually progressive
and associated with an abnormal inflammatory response
of the lung to noxious particles or gases. As a
consequence of airflow obstruction, dyspnoea and other
co-morbidities, patients with COPD have impaired
exercise tolerance and reduced activity, which contribute
to a reduced quality of life.
(GOLD 2011)
It is difficult to determine the exact prevalence of COPD
in the community as the diagnosis of COPD is often only
made following a first admission to hospital with an acute
exacerbation of respiratory symptoms (Bastin et al. 2010).
However, figures from general practice suggest that 5% of
men and 2% of women will be diagnosed as suffering
from COPD, although in the population as a whole it is
estimated that 11% of men and 8% of women have evi-
dence of obstructed airways when specifically tested by
spirometry (BTS 2006a).
Cigarette smoke is the main risk factor for COPD and
is associated with 80–90% of cases (Ryter et al. 2010).
However, not all smokers develop COPD and it is esti-
mated that 15–20% of smokers will develop the pathology
(Soares et al. 2010) with some evidence of women being
more susceptible to the effects of cigarette smoke than
men (Sørheim et al. 2010). However, it is also suggested
that 10–20% of COPD cases are a result of occupational
exposure to noxious particles, such as the combustion of
solid fuels (Kurmi et al. 2010), and long-term exposure to
traffic-related air pollution has been implicated in the
development of COPD (Andersen et al. 2010).
The survival rate for COPD varies between 5 and 30
years, but eventually cardiac and ventilatory failure will
occur. Avoidance of the precipitating factors listed below
and early detection of the disease will tend to improve the
prognosis:
• stopping smoking and reducing exposure to
atmospheric pollution;
• maintaining physical fitness through participation in
regular exercise;
 Management of respiratory diseases Chapter 6

• maintenance of good general health, including good
nutrition;
• prompt treatment of all acute infections.
As COPD is characterised by airways obstruction, the
greater the obstruction, the lower the chance of survival
(Pearson and Calverley 1995). Obstruction to flow is
measured by forced expiratory volume in one second (FEV1)
and together with age, FEV1 is the most important deter-
minant of survival. Therefore, COPD can be classified
according to the GOLD (2011) definition (Table 6.1).
Patients with COPD may also be classified according to
the frequency of chest exacerbations each year (NICE 2010)
or their level of breathlessness, as assessed by the Medical
Research Council (MRC) dyspnoea scale (Table 6.2).
Table 6.1  Spirometric classification of patients with
COPD according to GOLD (2011)
Stage Severity FEV1:FVC FEV1 %
predicted
I Mild COPD <0.7 <80
Although chronic bronchitis and emphysema coexist in
patients with COPD they can occasionally appear in isola-
tion. Therefore, a brief description of these pathologies
will now be presented.
CHRONIC BRONCHITIS
Definition
Chronic bronchitis is a chronic or recurrent increase in
the volume of mucus secretion sufficient to cause
expectoration when this is not caused by localised
bronchopulmonary disease. In the definition of this
disease, chronic/recurrent is further defined as a daily
cough with sputum for at least three months of the year
for at least two consecutive years and airways
obstruction that does not change markedly over periods
of several months (West 2008). Chronic bronchitis is a
clinical diagnosis (unlike the definition of emphysema).

II Moderate <0.7 50–80

COPD
Aetiology of chronic bronchitis
III Severe COPD <0.7 30–50
This is more common in middle-to-late adult life and in
IV Very severe <0.7 <30 men more than women (Clarke 1991) although recent
COPD data suggest that mortality is now rising faster in women
(Dransfield et al. 2006).
FVC = forced vital capacity; FEV1 = forced expired volume in one
second. Cigarette smoking is the chief culprit and, although in
the UK over 20% of the adult population continue to
smoke (DH 1997), only 15–20% of smokers may develop
chronic bronchitis. The reason for this is probably genetic
(Silverman et al. 2000) although the number of cigarettes
Table 6.2  The Medical Research Council smoked does have an effect on the progression of the
Dyspnoea Scale
disease.
In the larger, more proximal airways, exposure to
Grade Degree of breathlessness related noxious particles stimulates mucus hypersecretion, with
to activities an increase in the size and number of goblet cells
and submucosal glands. This results in a chronic cough
1 Not troubled by breathlessness except on
with sputum production and is often termed chronic
strenuous exercise
bronchitis (Jeffery 2000). There is also a decrease in the
2 Short of breath when hurrying on walking number and length of the cilia, all of which lead to
up a slight hill retention of mucus, repeated infections, obstruction of
airways and inflammation. In turn, this causes a release
3 Walks slower than contemporaries on the
of toxins that further damage airway structure and func-
level because of breathlessness, or has to
tion (Braman 2006).
stop for breath when walking at own pace
Atmospheric pollution (e.g. industrial smoke, smog and
4 Stops for breath after walking about coal dust) will also predispose to the development of the
100 m or after a few minutes on the level disease, which is therefore more common in urban than
in rural areas. It is more prevalent in socioeconomic
5 Too breathless to leave the house or
groups 4 and 5 (Yelin et al. 2006) and is costly in terms
breathless when dressing or undressing
of working days lost annually in the UK.

85
 Tidy’s physiotherapy

Exposure to risk: Pack-years EMPHYSEMA

Rather than simply recording a patient’s current smoking The prevalence of the condition is probably highest in
habits, a much better indicator of any potential
England when compared with the rest of Europe, espe-
deterioration in lung function is an assessment of
cially in the major centres of industry – although there is
pack-years, which is the number of packs (20 per pack)
often a family history of the disease. It is more common
smoked daily multiplied by the number of years of
smoking. For example, someone aged 60 years who has
in males (Corda et al. 2006).
smoked five cigarettes per day (0.25 of a pack) since the
age of 15 years has a lifetime exposure equal to 0.25 ×
45 = 11 pack-years. Another person of the same age
who smoked 30 cigarettes per day (1.5 packs) between Definition
the ages of 15 and 25 years (gave up until aged 40
years, since then has smoked one pack per day) has a Emphysema is a condition of the lung characterised by
lifetime exposure of (1.5 × 10) + (1 × 20) = 35 permanent dilatation of the air spaces distal to the
pack-years. terminal bronchioles with destruction of the walls of
these airways. It is nearly always associated with chronic
bronchitis from which it is difficult to distinguish during
life (West 2008).

Pathology of chronic bronchitis Causes and types of emphysema

The hallmark is hypertrophy, and an increase in number Causes and predisposing factors
of mucous glands in the large bronchi and evidence of
Congenital or primary emphysema may be caused by alpha1-
inflammatory changes in the small airways (Thurlbeck
antitrypsin deficiency. This is a rare inherited condition
1976). Some irritative substance stimulates over-activity
that affects 1 person in 4000 and results in the complete
of the mucus-secreting glands and the goblet cells in the
absence of one of the key anti-protease systems in the lung
bronchi and in the bronchioles, which causes secretion of
(Corda et al. 2006). The consequence is the early develop-
excess mucus. This mucus coats the walls of the airways
ment of COPD, especially if the patient is already a smoker
and tends to clog the bronchioles, which is functionally
(Senn et al. 2005). Although alpha1-antitrypsin deficiency
more important (West 2008). The cells increase in size
is responsible for less than 1% of cases of emphysema, its
and their ducts become dilated and may occupy as much
hereditary nature means that it is worth diagnosing. It
as two-thirds of the wall thickness (West 2008). The
should, therefore, be considered in any young COPD
airways become narrowed and show inflammatory
patient.
changes, which results in mucosal oedema, thus further
Emphysema may be secondary to other factors, such as:
decreasing the diameter of the airways. The ciliary action
is also inhibited. • obstructive airways disease, e.g. asthma, cystic
Airflow limitation in chronic bronchitis is more closely fibrosis, chronic bronchitis;
related to the dimensions of the distal (small) airways • occupational lung diseases, e.g. pneumoconiosis;
than proximal (large) airways (Hasegawa et al. 2006) and • compensatory to contraction of one section of the
this narrowing of the lumen of the airways is further lung, e.g. fibrous collapse or removal when the
emphasised during expiration by the normal shortening remaining lung expands to fill the space.
and narrowing of the airways. Consequently, the airways
obstruction is enhanced during expiration, with resulting Types of emphysema
trapping of air in the alveoli. The lungs gradually lose their
elasticity as the disease progresses. They will gradually
become distended permanently, which may eventually Definition
cause extensive rupture of the alveolar walls. After repeated
exacerbations caused by infection there is widespread Centrilobular (centri-acinar) emphysema tends to affect
damage to the bronchioles and the alveoli with fibrosis the respiratory bronchioles with most of the alveoli
and kinking occurring, as well as compensatory over- remaining normal. Panlobular (panacinar) emphysema
distension of the surviving alveoli. This is closely linked results in widespread destruction of most alveoli, as well
to and contributory to the development of emphysema as respiratory bronchioles.
(Hogg 2004).

86
 Management of respiratory diseases
Normal
Terminal
bronchiole
Respiratory
bronchiole
Capillary
network
Destruction of walls
Alveolus
Figure 6.1  Emphysematous changes in the lung.
Emphysema is usually of the panacinar (panlobular) type.
In centrilobular emphysema the upper zones of the lung
are usually affected. This causes gross disturbance of the
ventilation/perfusion relationship as there is a relatively
well preserved blood supply to the alveoli but the amount
of oxygen reaching the capillary is decreased owing to the
damage to airways proximal to the alveoli. Panacinar
emphysema predominantly affects the lower lobes; lower
lobe involvement is more common in individuals with
alpha1-antitrypsin deficiency (Stavngaard et al. 2006).
This has a less drastic effect on the ventilation/perfusion
relationship as the blood supply in the damaged areas is
decreased in proportion to the decreased ventilation in
those areas.
Pathology of emphysema
Smoking causes the clustering of pulmonary alveolar
macrophages (which are the major defence cells of the
respiratory tract) around the terminal bronchioles. These
macrophages are abnormal in smokers and release proteo-
lytic enzymes that destroy lung tissue locally. Polymor-
phonuclear leucocytes, necessary to combat infection
in the lung, release an enzyme that also destroys lung
tissue. The defence mechanism against the unwanted
action of these enzymes lies in the serum alpha1-
antitrypsin, which is normally present in the airway lining
fluids. Oxidants released by both cigarette smoke and the
leucocytes tend to inactivate the anti-proteolytic action of
the alpha1-antitrypsin, thus causing destruction of lung
tissue as seen in centrilobular emphysema (Stavngaard
et al. 2006).
Chapter 6
Emphysematous changes
Kinking
Emphysematous lesions
Subsequently, the walls of the airways become weak and
inelastic owing to the damage caused by repeated infec-
tions. They tend to act as a one-way valve as the walls
collapse on expiration. This causes air trapping and con-
sequent increase in the intra-alveolar pressure during expi-
ration. The alveolar septa break down and form bullae
(Figure 6.1).
During expiration the pressure from the trapped air in
the bullae may compress adjacent healthy tissue, thus
causing occlusion and trapping of air in that tissue. The
capillaries around the alveolar walls become stretched,
causing the lumen to decrease and atrophy to occur. This
causes an alteration in the ventilation/perfusion relation-
ship owing to the loss of surface area for gaseous exchange
and the decrease in blood supply resulting from damage
to the pulmonary capillary network.
CLINICAL FEATURES OF COPD
The most important clinical features arising in the respira-
tory system are cough, sputum, wheeze and dyspnoea. The
respiratory features will be considered initially, prior to a
brief description of the extrapulmonary manifestations
associated with COPD. Although the clinical features
arising in the respiratory system may alter depending on
the extent to which a patient has predominantly chronic
bronchitis or emphysema, the clinical features of COPD
will be broadly discussed. A comparison of the clinical
features of chronic bronchitis and emphysema will also be
87
 Tidy’s physiotherapy
discussed should one of these clinical entities predomi-
nate in the COPD patient.
Dyspnoea or shortness of breath
This occurs in patients with COPD and, together with the
energy-requiring consequences of chronic infection and
inflammation, leads to increased work of breathing
(Donahoe et al. 1989). The patient becomes progressively
more short of breath as the disease progresses. Shortness
of breath occurs initially on exertion, but as the disease
progresses it will gradually occur after less and less activity
and finally at rest. This disabling breathlessness is what
prevents the patient from working and gradually trans-
forms the patient’s state into one of severe exercise intoler-
ance and disability (Folgering and von Herwaarden 1994).
In a patient where an emphysematous component pre-
dominates, shortness of breath may progress more rapidly
during the progression of the disease.
In the patient where emphysema predominates they
may present with a ‘fish-like’ inspiratory gasp, which is
followed by prolonged, forced expiration usually against
‘pursed lips’. The latter creates back-pressure which tends
to prevent airways shutdown during expiration. Owing
to increased intrathoracic pressure the jugular veins fill
on expiration. A ‘flick’ or ‘bounce’ of the abdominal
muscles may be seen on expiration as the outward flow of
air is suddenly checked by the obstruction of the airways
(Figure 6.2).
Cough
The patient will complain of a cough for many years,
initially intermittent and gradually becoming continuous.
Fog, damp or infection increases it. The patient may also
complain of bouts of coughing occasionally on lying
down or in the morning. The cough and sputum produc-
tion are not associated with either mortality or disability,
and are reversible in most smokers once they stop smoking.
The cough is caused by either irritation of airway nerve
receptors because of the release of compounds from
inflammatory cells or from the presence of increased
mucus production.
Sputum
Some patients with COPD may be unproductive of
sputum. However, sputum production may be a common
feature (where chronic bronchitis predominates). This is
mucoid and tenacious, usually becoming mucopurulent
during an infective exacerbation.
Wheeze
Wheezing is a symptom described by as many as 80% of
patients with COPD. Wheezing is a characteristic feature
88
of obstructive lung disease, although it is also reported in
many other acute and chronic respiratory diseases. Wheez-
ing is caused by the sound generated by turbulent airflow
through the narrowed conducting airways and may be
worse in the mornings or may be related to weather
changes. If the wheeze is reversible following inhaled
medication this may be indicative of an asthmatic compo-
nent in the COPD patient.
Deformity
These patients often develop a barrel chest caused by
hyperinflation and use of accessory muscles of respiration.
The thoracic movements are gradually diminished and
paradoxical in-drawing of the lower intercostal spaces and
supraclavicular fossa may occur on inspiration. This is
associated with the difficulty of ventilating stiff lungs
through narrowed airways. The ribs become elevated by
the use of the accessory muscles of respiration, which may
become hypertrophied as a result and there is loss of
thoracic mobility. There may be a thoracic kyphosis plus
elevated and protracted shoulder girdles.
Cyanosis
This is a blue colouration of the skin caused by the pres-
ence of desaturated haemoglobin as a result of reduced
gaseous exchange. Cyanosis is also related to the develop-
ment of complications, such as poor cardiac output caused
by ventricular failure leading to increased peripheral
oxygen extraction. Cyanosis may also be caused by an
increase in red blood cells (polycythaemia) in response to
chronic hypoxaemia.
Cor pulmonale
This may occur in the later stages of COPD. The impaired
gas exchange in COPD caused by the disruption of ventila-
tion and perfusion and the resulting hypoxia leads to
widespread hypoxic pulmonary vasoconstriction. This
leads to an increase in pulmonary vascular resistance
resulting in pulmonary hypertension (Vender 1994). The
increase in the pressure within the pulmonary artery will
create a resistance, which the right ventricle must over-
come. This eventually leads to hypertrophy and dilatation,
a condition known as ‘cor pulmonale’.
Right heart failure leads to an increased pressure in the
peripheral tissues resulting in the development of periph-
eral oedema. The combination of renal hypoxia and the
increase in blood viscosity from polycythaemia increases
the systemic blood pressure and eventually leads to left
heart failure. The development of pulmonary oedema,
which exacerbates the hypoxia and low cardiac output
in patients with COPD, leads to a terminal stage of
the disease. The mechanism of this cycle is illustrated in
Figure 6.3.
 Management of respiratory diseases Chapter 6

Emphysematous bulla
(occupies space – does not
contribute to function)

Intrapleural pressure Intrapleural pressure

remains negative becomes positive
(subatmospheric)
Airway already kinked
Negative pressure exerts shuts down.
traction effect keeping Abdominal bounce –
airways open abdominal muscles are
sucked in as pressure in
the thorax becomes positive
A B

Pursing of the lips

creates resistance to
outflow raising pressure
in the bronchial tree
keeping open the bronchioles

Figure 6.2  End of expiration: (a) normal; (b) in emphysema; (c) pursed-lip breathing.

89
 Tidy’s physiotherapy
Ventilation/perfusion abnormality
Hypoxia
Hypoxic pulmonary vasoconstriction
Pulmonary hypertension
Right heart failure + renal hypoxia + polycythaemia
Increase in systemic blood pressure
Left ventricular failure
Figure 6.3  Mechanism of development of cor pulmonale
and congestive heart failure in COPD.
Lung function
There is reduction of FEV1 and the forced vital capacity
(FVC) is grossly reduced. The residual volume (RV) will
be increased at the expense of the vital capacity (VC)
because of air trapping and the inability of the expiratory
muscles to decrease the volume of the thoracic cavity. The
expiratory flow–volume curve is grossly abnormal in
severe disease; after a brief interval of moderately high
flow, flow is strikingly reduced as the airways collapse
and flow limitation by dynamic compression occurs. A
scooped-out appearance is often seen (Decramer 1989).
Blood gases
Ventilation/perfusion mismatch is inevitable in COPD
and leads to a low arterial oxygen pressure (PaO2) with or
without retention of carbon dioxide (CO2). As the disease
becomes severe, the arterial carbon dioxide pressure
(PaCO2) may rise, and there is some evidence that the
sensitivity of the respiratory centre to CO2 is reduced
(Fleetham et al. 1980), which may leave the respiratory
stimulus dependent upon the hypoxic drive. However,
more recent evidence suggests that the administration of
high levels of oxygen (>70%) in patients with COPD may
increase hypercapnia owing to the reversal of pre-existing
regional pulmonary hypoxic vasoconstriction, resulting in
greater dead space (Crossley et al. 1997).
Auscultation signs
There will be inspiratory and expiratory wheeze possibly
with added coarse crepitations if sputum retention is
present. The breath sounds are vesicular with prolonged
expiration.
90
Examination
The percussion note will be normal or hyper-resonant
because of air trapping.
X-ray signs
No characteristic abnormality is seen in the early stages of
the disease. If there is significant airways obstruction there
may be signs of chest over-expansion (flattening of the
diaphragm) and an enlarged retrosternal airspace.
Other non-respiratory
manifestations of COPD
Loss of skeletal muscle mass
The cause of loss of skeletal muscle mass is not fully under-
stood, but may be caused by a number of factors, including
energy imbalance, systemic inflammation, disuse atrophy
and hormonal changes (Loring et al. 2009). As a result
of pulmonary impairments, patients with COPD often
present with dyspnoea and hyperinflation, which results in
increased work of breathing (Loring et al. 2009).
Reduced exercise tolerance
As well as loss of muscle mass, skeletal muscle abnormali-
ties have been found in COPD. These include mor­
phological and metabolic abnormalities (Seymour et  al.
2009). Bernard et  al. (1998) found a 30% decrease in
thigh cross-sectional area in patients with moderate-to-
severe COPD compared with control subjects. There
is also evidence of change in muscle fibre type from
fatigue resistant fibres to those which have less oxidative
enzyme activity and altered mitochondrial function.
These are likely to contribute to an inefficient muscle
metabolism and loss of muscle strength and endurance
(Maltais et  al. 1997).
Increased cardiovascular risk
Cardiovascular disease is a common cause of mortality in
patients with COPD, which accounts for approximately
30% of deaths in patients with COPD (McGarvey et al.
2007). This may be attributed partly to common risk
factors, such as exposure to cigarette smoke and reduced
physical activity. Nevertheless, studies have shown that
after controlling for these factors, patients with COPD still
have an elevated risk of cardiovascular disease (McGarvey
et al. 2007).
Osteoporosis
Loss of bone mineral density and osteoporosis is a signifi-
cant problem in patients with COPD, affecting between
32 and 60% of patients (Bolton et al. 2004). Bone mineral
 Management of respiratory diseases
Figure 6.4  Blue bloater and pink puffer.
density has been related to severity of airways obstruction
in COPD (Bolton et al. 2004) and to exercise capacity in
men with COPD.
Varying clinical presentation   supply of antibiotics at home and receive a
in COPD
Within the spectrum of COPD, two extremes of clinical
presentation are recognised: type A and type B. At one
time these were classified either as ‘pink puffers’ (type
A) or ‘blue bloaters’ (type B) to correlate with the
relative amounts of emphysema and chronic bronchitis
respectively (Figure 6.4). While these definitions are
over-simplistic, it is worth remembering that patients
can present in dramatically different ways (Kesten and
Chapman 1993).
Blue bloaters
Patients with this syndrome often show the following
symptoms:
• obesity;
• comparatively mild dyspnoea;
• copious sputum which may become infected;
• low PaO2 and high PaCO2 (PaO2 > 8kPa; PaCO2 >
6.5kPa) because they tend to hypoventilate;
• central cyanosis with cor pulmonale;
• peripheral oedema;
• an increased residual volume but normal total lung
capacity, hence tidal volume is decreased.
Pink puffers
Patients with this syndrome often show the following
symptoms:
• an anxious expression;
• general thinness;
• severe breathlessness;
• little or no sputum production;
• relatively normal PaO2 and PaCO2 (PaO2 < 8 kPa;
Chapter 6
PaCO2 normal/low) because of hyperventilation
early on in the disease;
• central cyanosis and the development of cor
pulmonale in the later stages of the disease;
• generally no peripheral oedema until the late stages
of the disease;
• an increased total lung capacity because of
hyperventilation.
MEDICAL TREATMENT OF COPD
1. Decrease the bronchial irritation to a minimum. The
patient should be advised to stop smoking and avoid
dusty, smoky, damp or foggy atmospheres. Occupation
or housing conditions may need to be changed.
2. Control infections. All infections should be treated
promptly as each exacerbation will cause further
damage to the airways. The patient should have a
vaccination against influenza each winter. The main
organisms of concern are Streptococcus pneumoniae
and Haemophilus influenzae, which are usually
sensitive to amoxycillin or trimethoprim.
3. Control bronchospasm. Although bronchospasm is not
a prominent feature of this disease, drugs (e.g.
salbutamol) may be given to relieve the airways
obstruction as much as is possible.
4. Control/decrease the amount of sputum. Patients with
chronic bronchitis may present with excessive
bronchial secretions and are usually able to eliminate
this by themselves. However, during an episode
when secretions may become difficult to eliminate,
physiotherapy techniques, including postural
drainage; active cycle of breathing technique (ACBT),
including Forced Expiratory Technique (FET),
Positive Expiratory Pressure (PEP) and oscillating
PEP; may aid expectoration (Bott et al. 2009).
5. Oxygen therapy. Oxygen must be prescribed and
should be given with great care, especially if a normal
pH indicates a chronic compensated respiratory
acidosis (renal conservation of bicarbonate ions
(HCO3) to maintain pH within 7.35 to 7.45). In this
instance HCO3 is raised above 24 mmol/L whilst
PaO2 is low and the PaCO2 is raised. Controlled
oxygen may be given via a Ventimask (or equivalent)
with careful monitoring of blood gas levels.
6. Long-term oxygen therapy (LTOT). As respiratory
function deteriorates, the level of oxygen in the
blood falls leading to an increase in pulmonary
hypoxic vasoconstriction and deterioration in cardiac
function. In 1981, the Medical Research Working
Party examined the effects of supplementary low
concentrations of oxygen (24%) for 15 hours a day
in COPD and found that it reduced three-year
91
 Tidy’s physiotherapy
mortality from 66% to 45%. The British Thoracic
Society Guidelines (2006b) suggest that patients who
have a PaO2 of less than 7.3kPa, with or without
hypercapnia, and a FEV1 of less than 1.5 litres,
should receive LTOT. This therapy should be
considered also for patients with a PaO2 between 7.3
and 8.0kPa and evidence of pulmonary
hypertension, peripheral oedema or nocturnal
hypoxia.
7. Noninvasive ventilation (NIV). Indicated during an
acute exacerbation with type II respiratory failure
(see definition in section on Respiratory Failure)
(Lightowler et al. 2003; Nava and Hill 2009). NIV
offloads the diaphragm enabling it to rest whilst the
exacerbation resolves (Fauroux et al. 2003).
Medications
Drugs used in the treatment of respiratory disease fall
broadly into two categories: relievers and preventers.
• The relievers are used to reduce bronchospasm and
include the beta2 (β2) agonists (which may be
short- or long-acting), the anticholinergics and the
xanthene derivatives.
• The preventers may be used to prevent bronchial
hyper-reactivity and reduce bronchial mucosal
inflammatory reactions – they include the
corticosteroids.
β2 agonists
β2-agonists such as salbutamol (Ventolin) and terabuta-
line (Bricanyl) work by stimulating β2-receptors, which are
widespread throughout the respiratory system. These stim-
ulate adenylate cyclase, which leads to bronchodilation.
β2-receptors are also found in other tissues, including the
heart, although these are of the β1 subtype.
Even though modern bronchodilators are designed to
be β2-selective, they may still cause an increase in heart
rate and other side effects, including fine tremor, tachycar-
dia and hypokalaemia (low potassium) after high doses.
Inhaled therapy is therefore preferred to oral, as the former
limits the amount of drug that finds its way into the
general circulation. The long-acting β-agonist agents
salmeterol and eformoterol offer a more favourable
dose regimen, and respiratory physicians are adding a
long-acting β-agonist for patients who have not responded
fully to short-acting β-agonists and an anticholinergic
used together.
Anticholinergics
Anticholinergic bronchodilators work by preventing bron-
choconstriction, mediated by the parasympathetic nervous
system. Two agents are currently available: ipratropium
92
bromide and oxitropium bromide. Most studies suggest
that these agents are at least as potent as β-agonists when
used alone in COPD (Tashkin et al. 1986). A short-acting
bronchodilator (β2-agonist or anticholinergic) used ‘as
required’ is recommended as initial therapy in the British
Thoracic Society guidelines (BTS 2001).
Xanthene derivatives
The precise mode of action of the xanthene derivatives
such as theophylline and aminophylline remains some-
what uncertain, although they are moderately powerful
bronchodilators. They have, however, been shown to
improve symptoms in COPD by increasing the contractual
ability of the diaphragm (Murciano et al. 1989).
Corticosteroids
The role of inhaled steroids (beclomethasone, budeso-
nide) in COPD will vary from patient to patient. Steroids
work by reducing inflammation and reducing bronchial
hyperactivity. Trials have shown that about 10–20% of
COPD patients will improve significantly following a
short course of high-dose oral steroids (Gross 1995).
The most serious limitation to oral steroid therapy
is the risk of long-term side effects, which include
osteoporosis, adrenal suppression, muscle wasting, poor
immune response and impaired healing. However, a
positive response to corticosteroids justifies the adminis-
tration of regular inhaled steroids.
Mucolytic agents
Mucolytic drugs are used to reduce sputum viscosity
and improve clearance of secretions. A recent review
reported a small reduction in acute exacerbations and a
reduction in total number of days of disability (Poole and
Black 2010).
Drug delivery systems
The objective of inhaled therapy in COPD is to maximise
the quantity of drug that reaches its site of action while
minimising side effects from unintended systemic absorp-
tion. Most metered-dose inhalers (which are later described
in detail for asthmatic patients) are designed to deliver
particles of between 0.5 and 10 microns (micrometres).
Unfortunately, poor inhaler technique tends to mean that
only a relatively small proportion of the drug actually
reaches its site of action. It is therefore imperative that a
good inhaler technique be adopted (as described for
patients with asthma).
In acute exacerbations, when conventional inhalers
have proved inadequate, nebulisers may be used to deliver
a therapeutic dose of a drug as an aerosol within a fairly
short period of time, usually 5–10 minutes (BTS 2006b).
 Management of respiratory diseases
The type of nebuliser for home use consists of a compres-
sor or pump, a chamber and a mask or mouthpiece.
The compressor blows air into the chamber, where it is
forced through a drug solution and past a series of
baffles. The solution is converted into a fine mist, which
is then inhaled by the patient through the mask or the
mouthpiece.
PHYSIOTHERAPY TECHNIQUES   symptomatic and often have decreased daily life
IN COPD
The physiotherapy management for all diseases should be
aimed at symptom management once symptoms have
been identified during physiotherapy assessment. How­
ever, the following general aims of treatment will be
described. These aims therefore outline the physiothera-
peutic ap­­proaches to treatment of the patient with COPD.
General aims of treatment
The general aims are:
• to improve exercise tolerance and ensure a long-term
commitment to exercise;
• to give advice about self-management in activities of
daily living;
• to increase knowledge of the patient’s lung condition
and control of the symptoms;
• to relieve any bronchospasm, facilitate the removal
of secretions and optimise gaseous exchange;
• to improve the pattern of breathing, breathing
control and the control of dyspnoea;
• to teach local relaxation, improve posture and help
allay fear and anxiety.
Treatment in the early stages
Key point
The most important themes are maintaining exercise
capacity and patient education into self-management. In
addition, guidance should be provided with regard to
clearing the airways of secretions and establishing a
correct breathing pattern.
Increasing/maintaining exercise tolerance
The patient may be treated as an inpatient or as an outpa-
tient, in a health centre or at home by a community physi-
otherapist. It is important to see the patient regularly.
Advice should be given on taking regular exercises, for
example a short walk every day. If possible, the patient
Chapter 6
should be offered participation in a multi-disciplinary
comprehensive programme of pulmonary rehabilitation.
Definition
Pulmonary rehabilitation is an evidence-based,
multidisciplinary, and comprehensive intervention for
patients with chronic respiratory diseases who are
activities. Integrated into the individualized treatment of
the patient, pulmonary rehabilitation is designed to
reduce symptoms, optimize functional status, increase
participation, and reduce health care costs through
stabilizing or reversing systemic manifestations of the
disease.
(BTS 2001)
This definition focusses on three important features of
successful rehabilitation.
1. A multi-disciplinary approach, which may include
respiratory physicians, physiotherapists, occupational
therapists, dieticians, nurses, psychologists and
therapy assistants.
2. Attention to physical and social function through
exercise training, education, nutritional,
psychological, social and behavioral interventions.
3. Individualised to meet each patient’s needs
(BTS 2001).
There is now unequivocal evidence to suggest that pul-
monary rehabilitation improves both exercise capacity
and health-related quality of life (Lacasse et al. 1996;
Guell et al. 2006). In essence, the components of a pul-
monary rehabilitation programme include aerobic exer-
cise training, education about the background of the
disease, smoking cessation, compliance with medication,
nutritional support and energy-conserving strategies for
activities of daily living (ADLs). Pulmonary rehabilitation
programmes may also include psychosocial support with
regard to advice on benefits, sexual function and anxiety
management. National Institute for Clinical Excellence
(NICE) Guidelines (2010) recommend that all suitable
patients with COPD should be offered pulmonary reha-
bilitation, even after an acute exacerbation.
Inspiratory muscle training
The potential for fatigue of the ventilatory muscles is
now recognised as an important component of ventilatory
limitation in patients with COPD (Moxham 1990;
Green and Moxham 1993). Fatigue may be caused by a
combination of:
• increased mechanical load on the respiratory
muscles;
93
 Tidy’s physiotherapy
• reduced muscle strength;
• reduced energy supply to the respiratory muscles
(Roussos and Zakynthinos 1996).
It has also been established that respiratory muscle
weakness, which may be a predisposition to muscle
fatigue, is present in patients with COPD (Clanton and
Diaz 1995; Polkey et al. 1995). It therefore follows that
training techniques, which might specifically target the
respiratory muscles, may prove beneficial in improving
exercise tolerance in patients with COPD who may develop
respiratory muscle weakness because of a loss of muscle
mass (Geddes et al. 2004).
Removal of secretions
The active cycle of breathing technique (ACBT)
(illustrated on Figure 9.9, p.178)
This is a cycle of breathing control, thoracic expansion
exercises and the forced expiratory technique (FET), and
has been shown to be effective in the clearance of bron-
chial secretions (Prior and Webber 1979; Wilson et al.
1995) and to improve lung function (Webber et al. 1986).
Thoracic expansion exercises are deep breathing exer-
cises (three or four) which may be combined with a three-
second hold on inspiration (unless the patient is very
breathless when this may not be tolerated). This increase
in lung volume allows air to flow via collateral channels
(e.g. the pores of Kohn) and may assist in mobilising the
secretions as air is able to get behind the secretions. The
increase in lung volume during the inspiratory phase of
the cycle may also be achieved by the patient performing
a ‘sniff’ manoeuvre at the end of a deep inspiration.
Manual techniques, for example shaking, vibrations or
chest clapping, may further aid in removal of secretions.
The FET manoeuvre is a combination of one or two
forced expirations (huffs) against an open glottis (as
opposed to a cough, which is a forced expiration against
a closed glottis). An essential part of the FET manoeuvre
is a pause for some breathing control, which prevents an
increase in airflow obstruction.
Postural drainage/positioning
This may also aid sputum removal and may be combined
with the ACBT technique. The optimum position for
effectiveness must be established with each individual,
although postural drainage for the lower lobe segments
may be difficult as some patients may not tolerate the
head-down position or even lying flat. In many patients
the ACBT alone may be effective for many in the seated
position (Cecins et al. 1999) and changes in position
should be used to optimise gaseous exchange. In the
lateral position, the lower lung is always better ventilated,
regardless of the side on which the subject is lying,
although there still remains a bias in favour of the right
side because of its larger size when compared with the
94
left lung (Svanberg 1957). Perfusion is also preferential to
the lower lung in the lateral position in the spontaneously
breathing person (West 2008), although if pathology
exists within the lowermost lung gaseous exchange may
be compromised because of the presence of pulmonary
hypoxic vasoconstriction, which cannot be overcome by
gravity (Chang et al. 1993).
Humidification
If the secretions are very thick and tenacious the patient
may be given humidification via a nebuliser, usually neb-
ulised saline.
Improving the breathing pattern
The patient is taught how to relax the shoulder girdle in a
supported posturally correct position, such as crook half-
lying. Breathing control is taught following clearance of
secretions. If the patient is breathless, respiratory control
is regained starting with short respiratory phases and
allowing the rate to slow as the patient’s breathing pattern
improves.
Treatment in the later stages
It is imperative that patients with COPD are able to main-
tain as much independence and maximum function as is
possible through the support from the hospital or com-
munity healthcare team. During acute exacerbations, the
ACBT may be continued to assist clearance of secretions.
Breathing control should be emphasised so that the
patient can walk or climb stairs with confidence. Relaxa-
tion positions should be taught for regaining breathing
control after activity has made the patient breathless. If the
patient becomes very disabled, a walking frame may help
to retain some degree of independence as the arms are
fixed and accessory muscles of inspiration may be used.
Non-invasive positive-pressure ventilation
Tracheal intubation and mechanical ventilation providing
intermittent positive-pressure ventilation (IPPV) is used in
intensive care units or high-dependency units to manage
patients with deteriorating respiratory failure. However,
tracheal intubation may result in complications, including
tracheal injury and infection. Furthermore, it may be dif-
ficult to wean these patients off IPPV, resulting in a pro-
longed stay in intensive care.
Non-invasive positive-pressure ventilation (NIPPV) is
therefore indicated for the delivery of intermittent positive
pressure and may be applied via the nose or mouth using
a silicone mask attached to a bedside ventilator. Unlike
IPPV, NIPPV can be administered on a general ward for
patients in respiratory failure (Sinuff et al. 2000). The ven-
tilator is programmed to supplement the patient’s own
respiratory effort and, if required, oxygen therapy may be
 Management of respiratory diseases
given in conjunction with NIPPV. NIPPV can be used
during an acute exacerbation and has been shown to
improve quality of life and arterial blood gas pressures
(Meecham-Jones et al. 1995) and to reduce mortality in
patients with COPD (Brochard et al. 1995).
Physiotherapy will be required for short spells but fre-
quently throughout the day and sometimes at night. NIV
may be used to assist sputum clearance but, if unavailable,
intermittent positive-pressure breathing (IPPB) may also
be given to assist sputum mobilisation using a mask if the
patient is too drowsy to use a mouthpiece. Postural drain-
age may be necessary, if tolerated, together with rigorous
shaking applied during the expiratory phase of the ventila-
tor. Patients should be positioned appropriately in order
to facilitate gaseous exchange.
Suction via an airway or nasal suction may have to be
used as a last resort to remove secretions if the patient is
unable to cough spontaneously or effectively. If PaCO2 is
high and PaO2 is low the patient should not be given a
high concentration of oxygen. Drugs such as mucolytic
agents or bronchodilators may be provided through the
nebuliser attached to the ventilator. The patient should be
encouraged to sip drinks because dehydration makes the
secretions viscid.
As the patient recovers, treatment should be directed
towards that given in the ‘early’ stages, with special empha-
sis on a daily maintenance programme of regular exercise,
sputum clearance and breathing exercises.
Terminal care
The main theme is to keep the patient as comfortable as
possible. Treatment needs to be short and frequent. Non-
invasive nasal ventilation may be provided for home use.
Inhalations may be used to loosen and liquefy secretions.
Suction may be necessary and the GP may provide medi­
cation for the patient if the person is being managed
at home.
ASTHMA
Definition
Asthma is a clinical syndrome present in all age groups
but often starts in childhood and is a disease
characterised by recurrent attacks of wheezing and
breathlessness. The condition is caused by inflammation
and increased sensitivity of the airways. In an attack, the
intrapulmonary airways become swollen resulting in
reduced air flow during inspiration and expiration. The
severity of the narrowing of the airways varies over short
periods and is reversible either spontaneously or as a
result of treatment (WHO 2004).
Chapter 6
Types of asthma
It has been common practice to divide asthma into extrin-
sic and intrinsic forms. There is a degree of overlap and
many asthmatics, particularly adults, do not fall clearly
into either group.
Extrinsic asthma
Extrinsic (atopic) asthma occurs in younger age groups and
is caused by identifiable trigger factors, such as specific
allergens. Patients are usually sensitive to different factors
(e.g. pollen, house dust mites, feathers, fur, dust, pollution
and, occasionally, food, drugs and exercise) and have a
family history of similar sensitivities. Atopic subjects show
an immediate skin reaction, elicited by pricking the skin
through a drop of antigenic extract. Exposure to the pre-
cipitating factor causes a mucosal inflammatory allergic
reaction. This type of asthma tends to be episodic. House
dust mites provide the most common positive skin test in
Britain, being positive in 80% of children with severe
asthma. Extrinsic asthma is common in young people and
is associated with a family history of asthma, hay fever and
eczema, although new evidence suggests that the presence
of more than one of these factors is also associated with the
development of asthma in later life (Porsbjerg et al. 2006).
Intrinsic asthma
Intrinsic (non-atopic) asthma tends to occur in the older
patient as a chronic condition. This type of asthma is
precipitated by, or associated with, chronic bronchitis,
strenuous exercise, stress or anxiety. Respiratory infections
are also a common factor in precipitating acute attacks,
although the majority of these are viral in origin and
therefore may represent inappropriate use of antibiotics
(Shiley et al. 2010).
Aetiology and prevalence of asthma
The condition can occur at any age but is most common
in children, especially boys (ratio of about 3 : 2). Approxi-
mately 10% of children under 10 years of age in the UK
have bouts of coughing and wheezing related to narrowing
of the airways. Asthma accounts for more absences from
school than any other chronic disease, although days
lost from school may be under-estimated owing to the
under-diagnosis and under-treatment of childhood
asthma (Baena-Cagnani and Badelliono 2010).
Childhood asthma generally remits after puberty but it
may return in later life. Asthma that starts in middle age
is more common in women than men and remission in
this age group is rare. The majority of cases of asthma are
mild, although the course of the disease is unpredictable.
The mortality rate is unacceptably high and has shown
a slow rise since the 1960s; in 2008 in England and
95
 Tidy’s physiotherapy
Wales there were 1204 reported deaths as a result of
asthma (BTS 2008).
The rise in the prevalence of asthma has continued since
1988 but had been shown to decline by 2003 (Burr et al.
2006). However this decline in asthma prevalence is
thought to be a result of better disease management, as
more children are now using inhaled corticosteroids as a
preventive treatment (Burr et al. 2006). However, despite
the rise in the use of corticosteroids under-treatment and
inadequate appreciation of the severity of asthma by
patients and doctors are important factors in determining
mortality, with up to 86% of asthma deaths being prevent-
able. Those most at risk are the patients who under-
estimate their symptoms. About 15–20% of asthmatics do
not notice moderate changes in their airflow obstruction
(National Asthma Campaign 2002) and may quickly dete-
riorate until they suddenly present with severe asthma.
Patients with inadequately controlled, severe persistent
asthma are at a particularly high risk of exacerbations,
hospitalisation and death, and often have severely
impaired quality of life (Peters et al. 2006).
Pathology of asthma
In all types of asthma an underlying problem seems to lie
in abnormal reactivity of the airways; that is, they narrow
excessively in response to stimuli which would not affect
normal subjects (Bone 1996). The main pathological
changes occurring during an asthmatic attack are:
• spasm of the smooth muscle in the walls of the
bronchi and bronchioles (bronchoconstriction);
• oedema of the mucous membrane of the bronchi
and bronchioles;
• excessive mucus production and mucus plugging.
These changes result in airways obstruction. The bron-
chial walls become infiltrated with eosinophils and there
is thickening of the epithelial basement membrane.
At the end of an attack these changes are almost totally
reversible, but if attacks occur frequently then long-
standing changes will occur. Such changes are hypertrophy
of the smooth bronchial muscle, which increases the effect
of bronchial spasm during an attack; permanent thicken-
ing of the mucous membrane with an increase in the
number of goblet cells and mucous glands; over-distension
of the alveoli as a result of the trapping of air; and atel-
ectasis of alveoli when a bronchiole, already narrowed,
becomes blocked by mucus plugs.
Where the predominant factor precipitating asthma
is an allergic reaction there is antigen-mediated bron­
choconstriction. This means that the antigen (allergen or
precipitating factor) binds to two IgE molecules (immu-
noglobulin antibodies) on the membranes of mast cells
present in the bronchial lining. This binding releases
mediators that act on receptor sites on smooth muscle
cells, causing changes in intracellular cyclic adenosine
96
monophosphate (AMP) levels which result in muscular
contraction. The mediators histamine, neutrophil chemo-
tactic factor (NCF-A), platelet activating factor (PAF) and
eosinophil chemotactic factor (ECF-A) are stored in gran-
ules within the mast cells as pre-formed mediators. This
antigen-antibody reaction is part of the body’s immune
response and previous exposure to the antigen results in
greater bronchoconstriction.
Clinical features of asthma
Extrinsic asthma
In extrinsic asthma the onset is often sudden and parox-
ysmal, often at night. An attack starts with chest tightness,
dryness or irritation in the upper respiratory tract. Attacks
tend to be episodic, often occurring several times a year.
Their duration varies from a few seconds to many months
and the severity may be anything from mild wheezing to
great distress. The most predominant features are sum-
marised below.
Wheeze and dyspnoea
Dyspnoea may be intense and chiefly occurs on expiration,
which becomes a conscious exhausting effort with a short
gasping inspiration. Wheezing is always present on expira-
tion but may also occur on inspiration in severe asthma.
Cough
At the initial stage of an attack the cough may be unpro-
ductive and ‘barking’ in nature. It causes an increase in
bronchospasm and dyspnoea. As the attack subsides, the
cough becomes productive of casts or plugs of sputum.
Such plugs – made up of yellow viscid mucus and desq-
uamated epithelial cells and eosinophils – are often very
occasionally coughed up during acute attacks, which may
produce a marked relief of symptoms. A cough may be
the only presenting symptom of asthma, particularly in
children (Corraco et al. 1979).
Posture
The patient will prefer to sit upright with the shoulder
girdle fixed (by grasping a table or bed) to assist the acces-
sory muscles of respiration. The chest is hyperinflated.
Pulse
This is rapid and there may be an increased drop in blood
pressure during inspiration (>10 mmHg) owing to an
exaggeration in intrathoracic pressure swings caused by
severe airways obstruction (pulsus paradoxus). However,
pulsus paradoxus may be absent even in very severe
attacks of asthma. When it is present, the measurement
is easily performed with a sphygmomanometer and
provides a guide to progress and response to treatment
(Pearson et al. 1993).
 Management of respiratory diseases Chapter 6

Electrocardiogram mL During attack mL During recovery

This will show a tachycardia and may show signs of right
2
ventricular strain or the development of a large P wave (P 2
pulmonale). These abnormalities will return to normal as
the attack subsides. 1 1

Cyanosis 1 Seconds 1 Seconds

This may occur at a very late stage in the progression of Figure 6.5  Asthma: FEV1 and FVC reversibility during an
the disease because of worsening hypoxaemia (low PaO2) attack and recovery. 1 = before bronchodilator; 2 = after
if this is not corrected with adequate oxygen therapy. bronchodilator.

Blood gases
Analysis of blood gases provides important information
to help the management of severe asthma. The usual

10pm
10pm
10pm
10pm
10pm
10pm
10pm
10pm
10pm
10pm
10pm
10pm
finding is of a low arterial PaO2 (hypoxaemia) caused by
ventilation/perfusion mismatch and a low PaCO2 (hypoc-
apnia) because of the effects of hyperventilation. Later in 600
the disease process, the PaCO2 may be found to be high 500

Litres (min -1)

because the hyperventilation fails to compensate for the 400
fact that there are many under-ventilated alveoli which are 300
distal to the blocked bronchioles. When the PaCO2 is 200 Acute
found to be increasing and the pH is low this should be 100 attack
a danger sign that the patient may be becoming tired and 1 2 3 4 5 6 7 8 9 10 11 12 Days
be likely to need assisted ventilation if immediate improve-
6am
6am
6am
6am
6am
6am
6am
6am
6am
6am
6am
6am
ment cannot be achieved (BTS 2008). A

Breath sounds
10pm
10pm
10pm
10pm
10pm
10pm
10pm
10pm
10pm
10pm
10pm
10pm
These are vesicular with evidence of a prolonged expira-
tion and high-pitched wheeze. Crackles may also be heard
if sputum is present. During severe attacks with worsening
obstruction, the breath sounds may be diminished and 600
500
Litres (min -1)

occasionally become inaudible (silent chest) because of

diminished airflow. 400
300
200
Percussion note
100
The note may be hyper-resonant if the patient is Days
hyperinflated. 1 2 3 4 5 6 7 8 9 10 11 12
6am
6am
6am
6am
6am
6am
6am
6am
6am
6am
6am
6am
B
Chest X-ray
Radiography is not usually helpful in the management of Figure 6.6  Dipping charts in asthma. (a) Recording of peak
asthma. It usually shows only over-inflation, although flow at home showing deterioration before onset of acute
attack. Intervention when there is a chart like this can
may also show a pneumothorax if this is suspected.
prevent the attack. (b) During recovery there is still diurnal
variation. These patients are at risk and should have
Lung function long-term monitoring.
FEV1 and FVC drop during a severe attack with little sign
of reversibility (Figure 6.5). However, if FEV1 is measured
before and after giving bronchodilators, and there is a
15% increase in FEV1, this amounts to significant reversi- 1980). PEFR dips in the morning, particularly during the
bility. The FEV1 may be less than 30% of FVC. Total lung recovery phase (Figure 6.6). If the dip is severe (less than
capacity, FRC and RV may be increased because of over- 33% of predicted) then respiratory arrest may occur (BTS
inflation of the lungs. Recovery is associated with a reduc- 2008). In a severe attack, the PEFR may drop below 100 L/
tion in these lung volumes. Recordings of the peak minute. However, it should be noted that a normal PEFR
expiratory flow rate (PEFR) for a week at home will often when a patient is asymptomatic does not exclude a diag-
make the diagnosis of asthma obvious (Prior and Cochrane nosis of asthma (BTS 2008).

97
 Tidy’s physiotherapy

oxygen therapy be titrated according to the level of PaO2.

Table 6.3  Warning signs of an attack of acute
severe asthma
It may be evident on clinical examination, however, that
the asthmatic patient also has evidence of COPD. In this
situation examination of the blood gases will reveal
Early warning signs Signs of increasing
whether the patient has had raised PaCO2 levels for some
severity
time (a chronic compensated respiratory acidosis will be
Increase in symptoms Dyspnoea at rest evident on an arterial blood gas analysis) where the use of
controlled oxygen will be required. If a patient is reaching
Sleep disturbance Peak flow below 100 L/min a stage where the respiratory muscles are starting to fatigue
the PaCO2 may rise. In this situation immediate medical
Increase in Deteriorating blood gases
bronchodilator use
attention is required as the asthma is deemed life-
threatening and the patient is likely to require invasive
Fall in peak flow Pulsus paradoxus mechanical ventilation (Richards et al. 1993).
Decrease in exercise Tachycardia
tolerance Medications
Suitable drugs are discussed in the earlier section on the
management of patients with COPD. Their use is dis-
Between attacks cussed here particularly with regard to the treatment of
asthma.
No abnormality should be detectable between attacks,
although children with severe asthma may develop a β2 agonists
pigeon chest or have a persistent, low-pitched wheeze
The side effects of salbutamol (Ventolin) and terabutaline
with a productive cough.
(Bricanyl) include fine tremor, tachycardia and hypokalae-
mia (low potassium) after high doses.

Intrinsic (chronic) asthma Corticosteroids

This is less paroxysmal in character than extrinsic asthma
and is often associated with chronic bronchitis.
Clinical features are similar to those described above for
extrinsic asthma, but wheeze and dyspnoea tend to be
continuous and worse in the morning. Cough produces
mucoid sputum, respiratory infections occur with increas-
ing frequency and radiographs may show emphysematous
changes.
Acute severe asthma
As asthma is, by nature, a paroxysmal condition, acute
attacks that are resistant to bronchodilators may occur.
Such attacks are potentially life-threatening, so prompt
and effective treatment is imperative. In general, clinical
criteria are most helpful and the recognition by the person
that his or her asthma symptoms are worsening. Table 6.3
lists warning signs of an acute severe attack.
In a small proportion of asthmatic people, long-term oral
corticosteriods (e.g. beclomethasone and budesonide)
will be necessary. In circumstances when an attack super-
venes very rapidly, a short course of oral steroids (pred-
nisolone) is required. It cannot be emphasised enough
that this approach is safe and certainly much safer than a
poorly-controlled attack of asthma. There have been sug-
gestions that the adverse effects associated with long-term
steroids, such as osteoporosis, might be less common in
asthma but this has been shown to be untrue (Adinoff and
Hollester 1983). The introduction of inhaled corticoster-
oids in 1972 radically changed the management of asthma
as side effects from oral steroids were prevented.
Leukotriene antagonists
Oral inhibitors of leukcotriene action may help to
reduce the inflammatory component of asthma (Israel
et al. 1993).

Mucolytic agents and asthma

MEDICAL TREATMENT OF ASTHMA
Oxygen therapy
Unlike patients with long-standing COPD, patients with
asthma may tolerate higher levels of oxygen to correct
hypoxaemia. During an acute episode it is essential that
Mucolytic drugs are used to reduce sputum viscosity and
improve clearance of secretions. A recent review reported
a small reduction in acute exacerbations and a reduction
in total number of days of disability (Poole and Black
2010).

98
 Management of respiratory diseases
Other agents
Other types of medication that may be useful include:
• anticholinergic agents;
• long-acting β2 agonists;
• theophylline;
• salmeterol;
• chromones (sodium chromoglicate);
• antihistamines and ketotifen.
Delivery of medication
Metered-dose inhalers
It is good practice to use inhaled therapy for asthma. This
keeps the dose down and reduces side effects.
β2 agonists, anticholinergic agents and corticosteroids
are frequently prescribed in metered-dose inhalers (MDIs).
The particles leaving an MDI do so with considerable
velocity and even with a perfect technique of inhalation,
only about 10% of the dose reaches the respiratory tract
– the remainder is deposited in the mouth or swallowed
(Davies 1973). The MDI does have the advantage of being
small and portable and familiar to many asthmatics. The
MDI can also be used with a spacer, which virtually
removes oropharangeal deposition, thereby increasing
lung deposition to 20–30% (O’Callahan and Barry 1997).
Inhaled steroids can cause hoarseness and oral thrush so
a spacer device may be prescribed to minimise deposition
of large particles of the medication around the mouth and
throat.
A B
Figure 6.7  Breath-activated metered-dose inhalers. Photos courtesy of Melanie Reardon and Joanne Kenyon.
Chapter 6
Breath-activated devices (Figure 6.7) are primed before
actuation and the MDI is triggered by inspiratory airflow.
The airflow required is low and the triggering of the device
quiet enough not to disturb the inspiration. β2 agonists,
anticholinergic agents and corticosteroids can be pre-
scribed in this form of inhaler.
There are various dry powder systems (Figure 6.8):
• the Turbohaler is a multidose dry powder system
which requires an inspiratory airflow of only 60 L/
minute. Patients tend to find this system easy to use;
• the Disk/Accuhaler is a dry powder multidose system
used for the delivery of salmeterol and fluticasone
propionate;
• with Rotocaps each dose of medication is loaded
into the inhaler prior to use and so the inhaler needs
to be stored in a dry place. Rotocaps absorb moisture
and the particles can become too large to inhale.
Nebulisers
If asthma symptoms become severe, inspiratory airflow
may become limited to such an extent that the contents
of a MDI cannot be inhaled adequately. With a nebuliser,
a high-velocity jet of air or oxygen sucks liquid up a tube
and the liquid is broken into tiny particles which are
inhaled and deposited in the lungs (Rees et al. 1982)
(Figure 6.9). Ultrasonic nebulisers may also be used to
deliver medication, although there are currently insuffi-
cient data to verify their advantage over other nebulisers
in the management of patients with asthma and COPD
(Brocklebank et al. 2001).
99
 Tidy’s physiotherapy

A B

C D

Figure 6.8  Dry powder systems: (a) Diskhaler; (b) Turbohaler; (c) Disk/Accuhaler; (d) Rotocaps. Photos courtesy of Melanie Reardon
and Joanne Kenyon.

Guidelines for drug therapy
The British Thoracic Society (2001) introduced guidelines
on the drug management of asthma. Steps 1–3 below
apply to the treatment of less severe asthma, in an attempt
to control symptoms. Steps 4 and 5 apply to the treatment
of more severe asthma, when it may not be possible to
abolish symptoms. Stepping down and up this treatment
ladder is recommended to match therapy to the person’s
current need.
• Step 1: Inhaled short-acting β2 agonists p.r.n. (when
required), but not more than once daily. If needed
more than once daily, move on to step 2. No
prophylaxis (preventers such as inhaled
corticosteroids).
• Step 2: Inhaled short-acting β2 agonists p.r.n. Regular
low-dose inhaled steroids, such as 100–400 µg
beclomethasone twice daily or budesonide daily via
a large volume spacer.
• Step 3: Inhaled short-acting β2 agonists p.r.n.
Regular high-dose inhaled steroids, such as
800–2000 µg beclomethasone or budesonide
daily via a large volume spacer. In a very small
number of patients who experience side effects
with high-dose inhaled steroids, either the long-
acting inhaled β2 agonists option is used or a
sustained-release theophylline may be added
to step 2 medication.
• Step 4: Inhaled short-acting β2 agonists p.r.n. Regular
high-dose inhaled steroids, such as 800–2000 µg
of beclomethasone, or budesonide daily via a large
volume spacer. Add in long-acting inhaled β2
agonists or sustained-release theophylline or
high-dose inhaled bronchodilators.

100
 Management of respiratory diseases Chapter 6

Table 6.4  Peak flow action plan

Daily medication Seretide (purple inhaler)

One suck every morning
and evening

As-needed medication Salbutamol (blue inhaler)

Two puffs as needed

Best peak flow reading 390 L/min

when well

If unwell with Continue daily medication(s)

cough, wheeze, as above
breathlessness or tight Commence salbutamol (blue)
chest or peak flow Four puffs every four
310 L/min or below hours
Record peak flow readings
every four hours before
taking blue inhaler

If peak flow falls to Commence oral steroids

230 L/min eight tablets once a day
for three days
See your doctor within 24
hours of commencing oral
steroids

If the action plan does not help relieve your child’s

symptoms for four hours or peak flow reading falls to
150 L/min, then you must seek urgent medical attention.
Figure 6.9  Portable nebuliser.

• Step 5: Inhaled short-acting β2 agonists p.r.n. Regular Measurement of peak flow

high-dose inhaled steroids, such as 800–2000 µg of
beclomethasone, or budesonide daily via a large
volume spacer. Add in one or more long-acting
bronchodilators, as in step 4, plus regular oral
prednisolone as a single daily dose.
Management between attacks
The environment
This comprises identifying and removing the cause or
trigger, if known. For example, a patient may have to avoid
certain foods and damp. The home environment should
be cleaned regularly, bedding vacuumed frequently, and
synthetic fibres used in place of feathers for pillows and
quilts. Gor-tex mattress covers are not inexpensive but are
impervious to mites and their faecal particles. It may also
be of benefit to avoid certain domestic animals, although
getting rid of a loved family pet may provoke emotional
problems in children, which can make their asthma worse.
Desensitisation may be possible by injection of mild doses
of the allergen, which will have been identified by a skin
test, although avoidance of these allergens altogether is
advised.
Measurement of peak flow can be useful so that variability
of lung function is clearly seen and treatment is titrated
accordingly. The patient may then alter medication in
order to control his/her symptoms. This is based upon the
extent to which the peak flow deteriorates (60%, 40% or
30% of the patient’s expected value). An example of a peak
flow action plan, which will be kept by the patient for
reference and which is based on the British Thoracic
Society guidelines (2008), is shown in Table 6.4.
Inhaler technique
When drugs are administered by aerosol/inhaler it is
important that the patient be taught how to use the device
correctly. The use of various inhaler devices requires some
skill on the part of the patient and teaching the correct
method of use is an essential part of the prescription of
such treatment. Failure to master a metered-dose inhaler
occurs in many patients of all ages. The technique for a
metered-dose inhaler in which the drug is suspended in a
propellant is as follows.
1. Shake the inhaler. This disperses the drug uniformly
throughout the propellant.

101
 Tidy’s physiotherapy
2. Hold the inhaler upright and direct into the mouth. If it
is not held upright the metering chamber will not fill
correctly.
3. Start inspiration and press the activating mechanism.
The drug will be effective only if it is breathed in
during inspiration. Although there is some
controversy regarding the lung volume at which the
actuation should occur (Newman et al. 1981), it is
simpler to teach the person to discharge the inhaler
at the beginning of inspiration.
4. Breathe in slowly through the mouth. The flow rate of
inspiration should be slow (Newman et al. 1982).
This helps to reduce impaction on the pharynx and
allow for further penetration of the drug into the
bronchial tree, as flow is laminar rather than turbulent.
5. Hold the breath at maximum inspiration for 5–10 seconds.
This allows particles of the drug to settle on the airway
walls. Ideally, the breath should be held for 10 seconds.
6. Relax and allow easy expiration. Patients need to be
aware of when their inhaler is getting close to empty
and patients should be instructed to shake their
inhaler in order to gauge this. Another method is to
place the inhaler in water. If it floats symmetrically
upright then it is close to empty. It is always good
advice to instruct the patient to have two inhalers at
home, to avoid being caught out in an exacerbation
without adequate relief.
PHYSIOTHERAPY TECHNIQUES   Pulmonary rehabilitation
IN ASTHMA
As in patients with COPD, physiotherapy management for
asthma should be aimed at symptom-management once
symptoms have been identified during physiotherapy
assessment.
General aims of treatment
The principal aims are:
• to relieve any bronchospasm and to facilitate the
removal of secretions;
• to improve breathing control and the control of
dyspnoea during attacks;
• to teach local relaxation, improve posture and help
allay fear and anxiety;
• to increase knowledge of the lung condition and
control of symptoms;
• to improve exercise tolerance and ensure a long-term
commitment to exercise;
• to give advice about self-management.
The management of asthmatic patients should include
maintenance of a good general fitness and a vital part of
asthma management is to educate the patient.
102
Patient education
All asthmatic patients and their close relatives should be
aware of how to manage their asthma, and the physiother-
apist is integral in the education process. Prevention of
infection is important. The patient should have plenty of
fresh air, avoid smoky atmospheres and keep away from
people with infections such as bronchitis and influenza.
Stress or anxiety must be minimised as these can precipi-
tate an attack.
Patients must know what therapy to take and how to
take it, and where they should seek further help. All this
should be carefully planned beforehand and incorporated
into a written action plan and self-management strategy
(Amado and Portnoy 2006) which guides the patient to
increase treatment when their asthma becomes more
severe and to reduce treatment when it gets better (refer
to Table 6.4).
Acute attacks
Treatment during acute exacerbations will involve the
physiotherapist in aiding removal of excessive bronchial
secretions using the ACBT technique (see above), with the
addition of postural drainage, if tolerated. Percussion and
shakings should be applied sensitively as they may increase
bronchospasm. Breathing control and the adoption of
relaxed positions may be necessary.
Pulmonary rehabilitation has largely been confined to
patients with COPD, but there is now recognition that
other patient groups may benefit. The principles are the
same as those previously described for patients with
COPD, but with some additional considerations.
Patients with asthma are younger but very commonly
have a fear and inhibition of exercise (Cochrane et al.
1990) and therefore can benefit from improved cardi­
orespiratory fitness (Patessio et al. 1993). Also, unlike
patients with COPD, individuals with asthma usually
show a greater variability in airflow obstruction and are
more susceptible to exercise-induced exacerbations (EIEs).
Consideration needs to be given to the prevention of
exacerbations (such as by the self-administration of β2
agonists prior to exercise), although certain exercises –
for example swimming – are the least likely to cause an
EIE. In addition to whole-body programmes, inspiratory
muscle training may also be incorporated into the exercise
programme (as described previously for COPD patients).
Removal of secretions
Some patients, especially children, have constant excessive
secretions and may require sputum clearance techniques,
such as the ACBT, on a daily basis. It may be essential to
 Management of respiratory diseases
teach FET for clearing secretions without increasing
bronchospasm.
Relaxation
If the patient is able to practise relaxation it may be pos-
sible to ward off an attack when there has been exposure
to an allergen. The onset of an attack is often preceded by
a ‘tickle’ in the throat or a sensation of tightness in the
chest. Relaxation and breathing control in an appropriate
position may prevent an attack developing. ‘Appropriate
position’ depends on where the patient is and may have
to be against a wall or the back of a chair.
Breathing control
Breathing exercises may be taught with the aim of reducing
respiratory rate and/or tidal volume. Encouraging a longer
expiratory phase is helpful, but neither inspiration nor
expiration should be forced. This may be helped by count-
ing (e.g. ‘in 1-2, out 1-2-3’) and by manual pressure just
under the xiphisternum to encourage diaphragmatic excre-
tion. The patient must breathe at a rate and rhythm that
suits him/her. Children may be taught to breathe to a
nursery rhyme.
There is evidence that the Buteyko breathing technique
may help control symptoms of asthma; however, cost
implications of training staff in this technique and time
involved should be taken into consideration (Bott et al.
2009). Breathing exercises should be seen as an adjunct to
conventional asthma management and not as a replace-
ment for medication (Bott et al. 2009).
BRONCHIECTASIS
Definition
Bronchiectasis is a chronic inflammatory disease of the
lungs, defined as dilatation and destruction of bronchi
and bronchioles. It results from impaired lung defence
which results in repeated infection, inflammation and
destruction of the airways.
Bronchiectasis is identified by anatomical and morpho-
logical changes, which can be identified by high-resolution
computed tomography (HRCT). Although bronchiectasis
is distinct from COPD, it shares common symptoms of
impaired mucus clearance, chronic cough, recurrent infec-
tion, wheeze, dyspnoea, airflow limitation and decreased
exercise tolerance. Indeed, up to 50% of patients with
COPD have been found to have evidence of bronchiectatic
changes on HRCT scan (Patel et al. 2004).
Chapter 6
Types and prevalence  
of bronchiectasis
The condition most commonly affects the lower lobes, the
lingula and then the middle lobe. It tends to affect the left
lung more than the right, although 50% of cases are bilat-
eral. The upper lobes are least affected as they drain most
efficiently with the assistance of gravity. Broadly, there are
two types of disease.
Congenital bronchiectasis
This is very rare and occurs in Kartagener’s syndrome
(‘immotile cilia’ syndrome) where there is a congenital
microtubular abnormality of the cilia that prevents
normal cilial beating. It is characterised by bronchiecta-
sis, sinusitis, dextrocardia and complete visceral trans­
position. There may also be associated male infertility.
Acquired bronchiectasis
Bronchial obstruction and bacterial infection are the prin-
cipal factors responsible for this disease. Obstruction of a
bronchus, which may be caused by a tumour or foreign
body, will cause collapse of the lung tissue supplied by
that bronchus. Bronchiectasis may also occur following an
infection, which causes the production of sticky sputum
leading to obstruction of multiple small bronchi. Classi-
cally, this is associated with whooping cough, tuberculo-
sis, measles and pneumonia in childhood, when the
airways are smaller and therefore more easily ‘plug’ with
sputum (Shoemark et al. 2007). Very occasionally, bron-
chiectasis may occur as a late complication of tuberculosis,
which has affected the right middle lobe causing that
segment to collapse. It may also occur following lung
abscess and pneumonia, and be associated with immune
defects in patients with hypogammaglobulinaemia. Aller-
gic bronchopulmonary aspergillosis, which is associated
with an auto­immune response, can cause formation of
mucus plugs resulting in bronchiectasis of the medium-
sized bronchi.
Prevalence
The prevalence of bronchiectasis following a childhood
infection is decreasing as these infections are now treated
with antibiotics, but may occur in individuals with an
underlying disorder that predisposes them to chronic or
recurrent infection. This includes cystic fibrosis, immuno-
deficiency, HIV infection and primary ciliary dyskinesia
(Rosen 2006).
Pathology of Bronchiectasis
Bronchial obstruction may be localised (perhaps because
of an inhaled foreign body such as a peanut or broken
103
 Tidy’s physiotherapy
tooth, or obstruction caused by a tumour or enlarged
gland) or generalised (e.g. pneumonia that is slow to
resolve owing to whooping cough or measles).
The bronchial obstruction will cause absorption of the
air from the lung tissue distal to the obstruction and this
area will therefore shrink and collapse. This causes a trac-
tion force to be exerted upon the more proximal airways,
which will distort and dilate them. If the obstruction can
be cleared and the lung re-expanded quickly then the dila-
tation is reversible. Secretions may collect distal to the
obstruction if it is not relieved quickly and these become
easily infected. This causes inflammation of the bronchial
wall with destruction of the elastic and muscular tissue.
These infections occur repeatedly with the walls becoming
weaker and weaker. They will eventually dilate because of
the negative intrapleural pressure. As the disease advances,
the bronchi become grossly dilated and pockets contain-
ing pus are formed. The elastic and muscle tissue is
destroyed and the mucous lining is replaced by granula-
tion tissue with loss of cilia. Therefore, the mucociliary
transport mechanism is disrupted and passage of mucus
out of the lungs is therefore hindered.
Several types are recognised pathologically: tubular,
fusiform or sacular. The arterial vessels within the bron-
chial walls anastomose with the pulmonary capillaries and
this results in the common feature of haemoptysis.
Clinical features of bronchiectasis
Key point
Although symptoms often begin in childhood, diagnosis
is not usually made until adult life.
Cough and sputum
Patients complain of persistent cough with purulent
sputum from childhood. Initially, it would be present only
following colds or influenza, but if the disease is allowed
to progress in its severity the affected segments continually
accumulate purulent secretions, resulting in cough and
sputum production. The sputum is usually green, often
foul smelling and present in fairly large volume. The
breath is fetid. The cough is particularly troublesome on a
change of position and on rising first thing in the morning.
Initially, the sputum culture will isolate Haemophilus
influenzae and/or Staphylococcus. In the later stages of the
disease Pseudomonas aeruginosa and Klebsiella spp. may be
isolated.
Dyspnoea
Shortness of breath is noticeable only if the disease is
particularly severe and widespread. If the bronchiectasis is
104
localised, other well-ventilated and perfused alveoli
should maintain blood gases at a reasonable level,
although bronchospasm may be a feature particularly
during an exacerbation.
Haemoptysis
This occurs quite commonly, usually associated with an
acute infection. It can be life-threatening if severe and may
require surgical resection of the affected lung tissue.
Recurrent pneumonia
Characteristically this will affect the same sites and is a
common feature.
Chronic sinusitis
This occurs in approximately 70% of the patients.
General ill-health
Patients may suffer pyrexia, night sweats, anorexia, malaise,
weight loss, lassitude and joint pains.
Clubbing
In about 50% of patients fingers and toes become clubbed.
The first sign of clubbing is loss of the angle between the
nail and the nail bed. This is followed by curvature of
the nail and an increase in the soft tissue of the ends of
the fingers to form so-called ‘drumstick’ fingers.
Thoracic mobility
This gradually decreases, as do shoulder girdle
movements.
Radiography
Initially, the X-ray will be normal but the patient gradually
develops an increase in the bronchovascular markings
and sometimes shows multiple cysts with fluid levels
(Armstrong et al. 1995). Bronchography is used for accu-
rate localisation of the area affected and will reveal dilated
bronchi. A CT scan will show bronchial wall thickening
and dilation of the bronchi and cysts.
Prognosis of bronchiectasis
The vast majority of these patients can lead normal lives
with a nearly normal life expectancy provided the medical
care is adequate. However, possible complications are:
• recurrent haemoptysis (common);
• pneumonia (common);
• pleurisy and empyema;
 Management of respiratory diseases
• abscess formation (in lung/cerebrum) (rare);
• emphysema (rare);
• respiratory failure;
• right ventricular failure (commonly develops after
years of pulmonary sepsis and arterial hypoxaemia if
there is widespread bronchiectasis).
MANAGEMENT OF BRONCHIECTASIS
Principles of treatment
The anatomical picture makes very little difference to the
treatment of the disease.
• Relieve the obstruction before permanent damage
occurs (recognition of either localised obstruction or
appropriate treatment for whooping cough or
measles).
• Maintain and improve exercise tolerance, as some
patients with bronchiectasis become deconditioned
owing to fatigue and shortness of breath.
• Control infection. Antibiotics are given
prophylactically in all but very mild cases. The
dosage of the antibiotics should be altered if an
acute infection occurs. Intravenous treatment is
indicated for severe infections (Currie 1997).
Inhaled (delivered by a nebuliser) or continuous
oral therapy may be used for chronic sepsis and
more resistant pathogens (e.g. Staphylococcus aureus
and P. aeruginosa).
• Promote good health with a good diet and fresh air.
• Inhaled steroids may be used in order to reduce
inflammation and reduce the volume of sputum
produced (Elborn et al. 1992).
• Surgery to remove the area of affected lung may be
indicated in young patients with localised disease,
although there is conflicting evidence regarding the
efficacy of surgery when compared to conservative
treatment (Corless and Warburton 2000).
PHYSIOTHERAPY   increasing exercise capacity in patients with bronchiectasis
FOR BRONCHIECTASIS
Aims of treatment
The principal aims of physiotherapy in bronchiectasis are:
• to promote good general health and maintain or
improve exercise tolerance;
• to remove secretions and clear lung fields;
• to teach an appropriate sputum clearance regimen
for independent use;
• to educate the patient in the pathology and
management of the condition;
Chapter 6
• to teach the patient how to fit in home treatment
within his or her lifestyle.
Clearing secretions
Postural drainage may be indicated, if tolerated, for
patients with excessive bronchial secretions. The position
must be accurate for the areas of lung affected. Accuracy
is judged by production of sputum and by identification
of the affected areas on a chest radiograph. This minimises
the danger of secretion overspill into the least affected
side, which could cause spread of the disease or pneumo-
nia. Percussion, shaking and vibrations with the ACBT are
also necessary and must be accurately applied over the
affected area of the lungs.
The patient may be taught the FET. A flutter or PEP valve
may be used to facilitate the movement of peripheral
mucus plugs and pus into the trachea from where they are
cleared by coughing. NIV or IPPB may be used in the
breathless patient as an adjunct to reduce the increased
work of breathing during physiotherapy. The patient must
perform a combination of these treatments 2–3 times
daily. It is important to ensure that the patient has dispos-
able sputum pots and polythene or paper bags to dispose
of the infected sputum without the risk of reinfection or
endangering other members of the family. Should the
patient develop a cold or influenza, antibiotics must be
readily available together with physiotherapy so that infec-
tion and secretions can be cleared promptly.
In order to enhance sputum clearance, nebulisation of
sterile water, normal saline, hypertonic saline (care must
be taken in case of bronchial hyper-reactivity), β2 agonists
or a bronchodilator may be considered (Bott et al. 2009).
Maintaining exercise tolerance
Mobility of the thorax, good posture and good general
health are achieved by the patient performing a daily exer-
cise programme. This comprises general deep breathing,
maintenance of good posture and aerobic exercise, such
as brisk walking. The patient may also attend pulmonary
rehabilitation as this has been shown to be effective in
(Bradley and Moran 2006). The patient should also be
encouraged to partake in sports, such as jogging, walking,
cycling, tennis or swimming.
CYSTIC FIBROSIS
Cystic fibrosis (CF) is the most common hereditary disor-
der transmitted by a recessive gene, estimated to be present
in 1 in 25 people in the UK. CF is the most common life-
shortening autosomal recessive disorder in the Caucasian
population. It is caused by mutations in a single gene on
105
 Tidy’s physiotherapy
Definition
Cystic fibrosis (CF) is a life-shortening hereditary disease
affecting Caucasians estimated to affect 250,000 persons
worldwide. It is a complex, multisystem disease caused
by mutations of the CF transmembrane conductance
regulator gene (CFTR) (Ratjen and Doring 2003). The
mutations affect transport of ion and water transport
across the epithelial linings, resulting in thickened
secretions in the respiratory, gastrointestinal and
reproductive tracts.
the long arm of chromosome 7 that encodes the CF trans-
membrane conductance regulator (CFTR) (Ratjen and
Doring 2003).
Pathology of CF
Mutations in the CFTR gene result in defective chloride
transport, which is accompanied by decreased transport of
sodium and water in the epithelial cells in the respiratory,
hepatobiliary, gastrointestinal and reproductive tracts, and
in the pancreas (Quinton 1990). This results in dehydra-
tion and, hence, an increase in the viscosity of secretions
that are associated with luminal obstruction and scarring
of various exocrine ducts (Oppenheimer and Esterly
1975). Other than in the respiratory system, the resultant
clinical manifestations include pancreatic insufficiency,
diabetes mellitus, azoospermia in affected men and evi-
dence of biochemical liver abnormality in up to 80% of
children (Ling et al. 1999).
The primary causes of morbidity and mortality in
patients with CF, however, are bronchiectasis and obstruc-
tive pulmonary disease; the latter accounts for over 90%
of deaths. Infants with CF have persistent endobronchial
bacterial infections (Abman et al. 1991) which are associ-
ated with an intense inflammatory response that damages
the airway and impairs local host defence mechanisms
(Konstan and Berger 1993). Continuous inflammation
coupled with thickened pulmonary secretions leads to
airways obstruction and hyperinflation (Davis et al. 1996).
Hyperinflation becomes a marked feature of the disorder
leading to altered pulmonary mechanics which cause the
inspiratory muscles, particularly the diaphragm, to be
foreshortened prior to contraction. In such cases even a
small change in breathing pattern (Bellemare and Grassino
1982) or an increase in ventilatory requirement induced
by exercise could be enough to induce inspiratory muscle
fatigue (Levine and Guillen 1987).
Pulmonary changes
• Excessive mucus. There is excess mucus production,
especially in the small bronchi and bronchioles.
106
These respiratory passages are structurally normal at
birth but become blocked by mucus plugs. Lung
disease in CF is also characterised by impaired
mucocilary clearance of secretions.
• Viscid mucus. The abnormality in the mucous glands
results in production of mucus with a reduced water
content so that the secretions produced are very
viscid and stick to the bronchial walls.
• Infection. The accumulated mucus provides a
medium for bacterial growth and so the secretions
become infected and purulent. This leads to
irritation of the bronchial wall tissue, which then
becomes inflamed.
• Bronchiectasis. Inflammation leads to weakening of
the bronchial walls and dilatation occurs as in
bronchiectasis.
• Lack of development of lung tissue. Mucus and
inflammation resulting in airway obliteration
inhibits the development of normal lung tissue.
Other pathological changes
Fibrosis of the pancreas causes digestive malfunction and
may lead to the development of diabetes. In addition,
skeletal muscle atrophy and osteoporosis are features of
late disease (Elborn 2007). Intestinal obstruction may
occur as a result of gallstones or faecal impaction. In
newborn babies there is intestinal obstruction – known as
‘meconium ileus’ – because there is excess meconium (a
greenish black viscid discharge from the bowel of newborn
babies) which plugs the small intestine necessitating
emergency surgery. Right ventricular hypertrophy occurs
because of pulmonary congestion, which develops as
fibrosis, and thickening of the pulmonary arterial walls
takes place.
Prognosis of CF
With early diagnosis and good management, the life
expectancy of patients with CF is increasing and survival
may be to the fourth or fifth decade (Elborn et al. 1991).
The majority, however, die before 40 years of age from
respiratory failure related to pulmonary infection. Indeed,
85% of mortality occurs as a result of lung disease (Flume
et al. 2009). In addition to the relentless progression of
lung disease, acute exacerbations of chronic infection
adversely affect the nutritional status of these patients.
During the terminal phase of their life, many patients with
CF enter into a vicious cycle of repeated respiratory exac-
erbations with evidence of deterioration in lung function
measurements and declining bodyweight (Elborn et al.
1993). This evidence strongly suggests that the systemic
consequences of infection and inflammation are, in part,
responsible for weight loss in patients with CF. Chronic
infection may also cause anorexia because of physical
 Management of respiratory diseases
factors such as increased mucus production and the
anorectic effects of cytokines.
Thus, in patients with CF there may be reduced energy
intake, reduced nutrient absorption as a result of
mal­digestion, and an increase in energy expenditure
resulting from abnormal pulmonary function and sepsis
(Bell et al. 1996).
Clinical features of CF
Children
At birth, the infant is normal, but symptoms of organ
dysfunction can appear soon after. The presenting features
vary widely.
• Meconium ileus. This may present in approximately
10% of infants and is caused by the abnormally
viscid nature of the meconium, causing obstruction
of the terminal ileum.
• Failure to thrive and gain weight. This results from
chronic malnutrition.
• Cough producing copious, often purulent, sputum.
Recurrent S. aureus infections are common and
Pseudomonas spp. and Burkholderia capacia colonise
the respiratory tract.
• Dyspnoea. This is particularly evident during an
exacerbation.
• Wheezing. This is caused by airway obstruction as a
result of inflammation and bronchospasm.
• High level of sodium in sweat. Sweat sodium and
chloride concentrations are elevated (sweat sodium
>7 mmol/L) in children under 10 years of age. The
sweat test is reliable in older children and adults and
is a reliable diagnostic sign.
• Frequent, foul-smelling stools. This is because of
malabsorption and steatorrhoea (fat in the stools)
because of secondary dysfunction of the exocrine
pancreas.
Adolescents and adults
• Progressive breathlessness. This may be associated with
infective exacerbations and increasing disease severity.
• Reduced FEV1 and deteriorating blood gases. Pulmonary
function tests deteriorate as chronic airways
obstruction develops. As the disease progresses,
ventilation/perfusion imbalance occurs leading to
hypoxaemia and pulmonary hypertension.
• Continued wheezing and productive cough. This is
associated with purulent sputum from which strains
of Pseudomonas spp., Staphylococcus spp. or B. capacia
may be cultured.
• Haemoptysis. This occurs secondary to bronchiectasis.
• Chest radiograph. This will show hyperinflation and
bronchial wall thickening, particularly in the upper
zones and bronchiectasis.
Chapter 6
• Finger clubbing. This is associated with bronchiectasis.
• Puberty delayed. This may be delayed for both male
and female patients. Most women have normal or
near-normal fertility, although pregnancy may be
inadvisable if pulmonary function is less than 60%
of expected.
• Infertility in males. This occurs because of blockage of
the vas deferens, which is either absent or blocked,
although they can produce sperm.
• Lung function tests (LFTs). There is reduction of the
FEV1/FVC ratio and the FVC is grossly reduced. The
RV will be increased at the expense of the VC because
of air trapping and the inability of the expiratory
muscles to decrease the volume of the thoracic cavity.
• Blood gases. Ventilation/perfusion mismatch is
inevitable in CF and leads to a low PaO2 with or
without CO2 retention. As the disease becomes
severe, the arterial PaCO2 may rise and a diffusion
abnormality will also be apparent.
• Auscultation. There will be inspiratory and expiratory
wheeze with added coarse crepitations.
• X-ray. No characteristic abnormality is seen in the
early stages of the disease. If there is significant
airways obstruction there may be signs of chest
over-expansion (flattening of the diaphragm) and an
enlarged retrosternal airspace.
Complications
• Haemoptysis. This is usually mild but frank
haemoptysis may occur occasionally.
• Spontaneous pneumothorax. This may occur because of
rupture of emphysematous bullae.
• Osteoporosis. There has been recent recognition of the
high prevalence of low bone mineral density leading
to osteoporosis and an increased susceptibility to
fractures (Haworth et al. 1999; Elborn, 2007).
• Liver disease. This usually presents as biliary cirrhosis
and may be associated with portal hypertension and
oesophageal varices.
• Diabetes mellitus. This results from progressive fibrosis
damaging the exocrine glands that produce insulin.
• Deformity. These patients often develop a barrel chest
as a result of hyperinflation with use of accessory
muscles of respiration. There may be evidence of a
poor posture, including kyphosis and lordosis, and
associated musculoskeletal pain.
• Cor pulmonale. This may occur in the later stages of
the disease.
Social–psychological problems
The disease carries with it some unfortunate social
and psychological problems. Coughing and spitting are
antisocial, so people, in avoiding the patient, are unwit-
tingly unkind. The parents may feel guilty as they are
carrying the gene. They have to spend a lot of time with
107
 Tidy’s physiotherapy
the patient, which creates resentment in siblings. The
patient, on reaching adolescence, may become resentful of
treatment and his/her increasing inability to participate in
a full social life. Clearly, this is only a brief mention of the
total picture of which the physiotherapist must be aware.
Terminal features
The terminal features include respiratory failure, cyanosis,
cor pulmonale and severe nutritional depletion (acceler-
ated loss of lean body mass and fat mass).
MANAGEMENT OF CF
General principles
Paediatric and adult patients with CF should receive care
from a specialist CF centre. A low-fat, high-calorie diet is
recommended, supplemented with vitamins. In addition
to maintaining or improving dietary status, treatment of
CF is directed towards the correction of organ dysfunction
(Davis et  al. 1996), including pancreatic-enzyme replace-
ment and reversal of secondary nutritional and vitamin
deficiencies (Ramsey et  al. 1992), although the majority
of treatment is directed towards the management of abnor-
malities of pulmonary function. This includes clearance
of lower-airway secretions (Zach and Oberwaldner 1989),
treatment of persistent pulmonary infections (Turpin and
Knowles 1993) and the alleviation of the symptoms of
pulmonary dysfunction, especially breathlessness, and
with emphasis on the importance of regular exercise.
Owing to abnormalities of pulmonary function, patients
with CF ventilate excessively and ineffectively at all work
levels compared with subjects with normal lung function
(Cerny et al. 1982). This results in loss of functional status
because aerobic exercise in CF is limited by both cardio-
vascular and pulmonary mechanisms. Thus, maintenance
of exercise capacity in patients with CF is imperative.
Medications
Antibiotics
Antibiotics are essential and the patient will be prescribed
one form or another for life. There is much evidence to
suggest that aggressive intravenous antibiotic therapy in
children with CF has resulted in a significantly improved
survival rate (Turpin and Knowles 1993; Elborn et al.
2000). More recent investigations suggest that the use of
prophylactic antibiotics is associated with a reduced
requirement for additional courses of oral antibiotics and
fewer hospital admissions in the first two years of life,
although no effect on infant lung function has been iden-
tified (Smyth and Walters 2000). In older patients with CF
who are chronically infected with Pseudomonas spp., no
108
differences in lung function or mortality rate were identi-
fied between 2 groups of 30 patients who were given either
elective or symptomatic antibiotic therapy over a 3-year
period (Elborn et al. 2000). There is no sound evidence
for or against the use of chronic inhaled antibiotics for
the treatment of P. aeruginosa in this population (Flume
et al. 2007).
Bronchodilators
These may be useful when there is airways obstruction
which is reversible. During an acute exacerbation, a neb-
uliser may be used at home.
Oxygen therapy
Oxygen therapy may be appropriate in the terminal stages
when there is persistent hypoxaemia. Bubble-through
humidification should be avoided because of an increased
risk of infection (Bott et al. 2009).
Mucolytic agents
Because lung disease in CF is characterised by impaired
mucociliary clearance, recurrent bronchial infections
and inflammation, methods that may enhance the
removal of retained bronchial secretions may act to lessen
the destructive inflammatory process in the airways
(Solomon et al. 1996).
Nebulised hypertonic saline has been shown to increase
mucociliary clearance immediately after administration.
This may have a long-term beneficial effect, although the
effect on pulmonary function tests, quality of life and
frequency of exacerbations remains unclear (Wark and
McDonald 2000). Care must be taken as hypertonic saline
may induce bronchospasm. Recombinant human deoxyri-
bonuclease (rhDNase) is currently used to treat pulmo-
nary disease in patients with CF by facilitating protein
breakdown in pulmonary secretions, thereby aiding expec-
toration (Christopher et al. 1999).
PHYSIOTHERAPY IN CF
Key point
Regular exercise and frequent expectoration of sputum
for life is an essential part of the treatment of the
pulmonary features of CF, and airways clearance is
currently recommended as soon as the diagnosis is
made. The treatment approach should be adapted to
changes in the patient’s lifestyle as he/she matures and
as the disease progresses.
 Management of respiratory diseases
The aims of physiotherapy are:
• to reduce bronchospasm and to clear the lung fields;
• to encourage activities for maintaining physical
fitness/increase exercise tolerance;
• to train postural awareness and relaxation;
• to educate the patient in self-management.
Clearing lung fields
This is the cornerstone of management of patients with CF
because the primary causes of morbidity and mortality are
bronchiectasis and obstructive pulmonary disease – the
latter accounts for over 90% of deaths. It is important that
the parents and the rest of the family be involved in the
treatment of the child at a young age so that physiotherapy
can become an accepted routine.
Chest clearance techniques in the infant include the use
of postural drainage, percussion and shaking. The optimal
position is usually sitting in the upright position, as the
infant will spend much of their time in supine lying. Prior
to these techniques it is useful to have an active game with
a child so that he or she laughs, producing deeper respira-
tion and then becoming breathless. This is required twice
a day, every day, even when the patient is apparently well,
as there is some evidence that inflammation and infection
exist during infancy (Konstan et al. 1994).
Key point
During exacerbations, or when the child has an upper
respiratory tract infection, these treatment sessions may
have to be increased up to as much as six times a day.
A baby may be positioned on a pillow on the knee of
either the physiotherapist or parent. The physiotherapist
has to identify the most effective position for each indi-
vidual patient and relate the treatment to the home situ-
ation. As the child grows, there comes a stage where it may
be necessary to position for drainage using cushions if
secretions are evident in the lower zones. A tipping frame
that supports the patient totally is more comfortable for
draining the anterior and lateral segments of the lower
lobes, and middle lobe or lingula. Adolescents and adult
patients may have blocks made so that their own bed may
be tipped.
In addition to postural drainage and manual tech-
niques, the use of a PEP mask and the Flutter device can
be used to facilitate the clearance of secretions by enhanc-
ing expiratory airflow (Freitag et al. 1989). Infants tend to
swallow their secretions so for children under 3 years of
age and babies the sputum needs to be cleared by a tissue.
Disposal of infected sputum should be discussed with
parents, relatives or patient, as it is essential to avoid
reinfection.
Chapter 6
Recent research has highlighted that there is no statisti-
cally significant difference between ACBT, autogenic drain-
age, PEP and Flutter (in the sitting position) over one year
when examining FEV1, quality of life or body mass index
(BMI) (Pryor et al. 2010). Again, NIV and IPPB may be
used as an adjunct during chest clearance physiotherapy
to minimise fatigue of the respiratory muscles.
Some form of humidification is useful to reduce the
viscosity of the mucus and may be applied using a mouth-
piece and nebuliser. Ultrasonic nebulisers have been
shown to be preferred by CF patients (Thomas et al. 1991).
For babies and children, a mask may be necessary. Saline
solution may be used as a mucolytic agent. For home use,
patients may have an electric compressor with a nebuliser.
As soon as the patient is old enough he/she should be
encouraged to become involved in the treatment. The
person should also be encouraged to expectorate the secre-
tions and not to swallow the sputum, as this may cause
an exacerbation of the abdominal symptoms. During exac-
erbations of infection, patients may be admitted to hospi-
tal where intensive physiotherapy is essential.
A community physiotherapist should visit the patient’s
home at regular intervals and will become very well known
to the involved family. The patient has to attend regular
follow-up clinics to be seen by a chest specialist, as well
as being taken care of by the GP. It is also essential that
the patient be seen regularly by the physiotherapist so that
treatment can be updated and problems discussed.
Maintenance of physical fitness/
increasing exercise tolerance
Aerobic fitness in both children and young adults with CF
can be improved by aerobic exercise training (Kaplan et al.
1991). Higher levels of aerobic fitness in patients with CF
have been shown to be associated with a significantly
improved length of survival (Nixon et al. 1992). Exercise
has also been shown to decrease breathlessness (O’Neill
et al. 1987), improve quality of life (de Jong et al. 1997)
and also offers an important contribution to sputum
expectoration (Sahl et al. 1989).
Parents of an infant with CF should be encouraged to
treat the child as normally as possible so that the child
joins in physical activities at school and with friends at
weekends. It is helpful for the parents to meet the child’s
teachers so that they know to encourage the child to par-
ticipate fully in school life.
Adult patients may benefit from regular swimming or
short sessions of jogging, and, if possible, should be
encouraged to attend the hospital or clinic when clinically
stable to have their baseline exercise capacity measured.
This will allow the physiotherapist to recommend a level
of exercise to provide an appropriate training effect. It is
also important to establish the goals of an exercise pro-
gramme and to tailor the programme to the patient’s level
of fitness and disease severity.
109
 Tidy’s physiotherapy
Terminal stages
The advanced stages of CF are characterised by repeated
exacerbations, reduced mobility and, eventually, respira-
tory failure. As the blood gases deteriorate and the PaCO2
begins to rise as a result of ventilatory failure, NIPPV may
be indicated, particularly if awaiting heart/lung transplan-
tation. This is a distressing time for the patient, the family
and the multi-disciplinary team, as the patient becomes
very ill and recognises that death is imminent. The family
will require a great deal of emotional support from the
multi-disciplinary team.
The principal theme is to keep the patient as comfort-
able as possible, which usually means sedation using mor-
phine or one of its derivatives to relieve the sensation of
breathlessness and reduce anxiety. It is inappropriate to
discontinue contact with the physiotherapist, even though
active treatment is no longer effective. The aim in the
terminal stages of the disease is positioning of the patient
in high side lying or forward lean sitting to make the
person as comfortable as possible and to assist with the
clearance of secretions from the upper airways if these
become uncomfortable and distressing for the patient.
Nasopharangeal suction is not indicated in the terminal
stages of the disease.
Surgery
The maintenance of mobility is essential for those patients
who are waiting for heart/lung transplantation if this is
indicated. Although exercise tolerance at this stage of the
illness may be restricted, the physiotherapist should main-
tain muscle strength and cardiovascular function. Postop-
eratively, rehabilitation should be extensive in order to
maximise function and quality of life.
RESTRICTIVE PULMONARY DISEASES
Pneumonia
Definition
Pneumonia is an acute inflammation of the lung tissue
– the alveoli and adjacent airways.
Classification
Pneumonia may be classified in many ways, for example:
• according to its anatomical distribution (e.g. lobar,
which is confined to one lobe, or
bronchopneumonia, which is a more widespread,
patchy infection);
• according to its microbiological cause.
110
In clinical terms, it may also be defined as:
• according to where the infection is acquired (i.e. in
the community or in hospital);
• according to whether the patient is
immunocompromised (e.g. by AIDS).
All of these factors may determine the outcome of the
disease, the likely causative factors and the clinical features
of the disease.
Community-acquired pneumonia
Infection is acquired through the inhalation of droplets
containing the specific microorganism and the individual
is unable to overcome the infection through the natural
pulmonary defence mechanism.
Community-acquired pneumonia is a common
pulmonary disease and may be responsible for over 1
million hospital admissions a year in the UK. The micro-
biological cause does, however, tend to affect different
age groups.
• Streptococcus pneumoniae pneumonia is the most
prevalent community-acquired pneumonia and
affects all age groups.
• Mycoplasma pneumoniae pneumonia usually occurs in
adolescents and young adults.
• Influenza, parainfluenza, measles and adenovirus
pneumonias are more common in children and the
elderly.
• Chickenpox pneumonia occurs in adults.
• Respiratory syncytial virus (RSV) is an important
cause of morbidity and mortality in children under
two years of age.
• Legionella pneumophilia infection (Legionnaire’s
disease) may occur in all age groups but is more
common in men than women. It thrives in warm
water and frequently contaminates badly maintained
air-conditioning systems.
• Haemophilus influenzae may produce
bronchopneumonia in those with pre-existing
pulmonary disease (e.g. chronic bronchitis). It is
therefore more common in the elderly.
• Staphylococcus pyogenes, Klebsiella pneumoniae
and M. pneumoniae infections are rare in healthy
individuals but may commonly complicate viral
pneumonia.
Predisposing factors
These are: winter or spring; overcrowding where bacteria
and viruses are easily transmitted; alcoholism; smoking
(cigarette smoke and alcohol depress ciliary function and
phagocytosis); atmospheric pollution; lower socioeco-
nomic groups; pre-existing respiratory disease. The disease
may also occur secondary to impaired consciousness and
malnutrition.
 Management of respiratory diseases
Pathological changes
The invading organism causes inflammation in the bron-
chioles and alveoli. The exudate spreads into neighbour-
ing alveoli to provide a medium for rapid spread of
bacteria. The alveoli become filled with red blood cells,
leucocytes, macrophages and fibrin (red hepatisation),
and there is congestion throughout the lobe. The overlying
pleural surface is inflamed and a pleural effusion may
develop. Resolution occurs when the leucocytes engulf the
bacteria and macrophages clear the debris by phagocytosis
(grey hepatisation).
In lobular or bronchopneumonia the inflammation is
scattered irregularly in the lungs whereas in lobar pneu-
monia the inflammation is spread throughout but
contained within one entire lobe. Without treatment, reso-
lution occurs by liquefaction of the consolidation, which
is then expelled by coughing.
Clinical features
The onset may be sudden (lobar pneumonia) or gradual
(bronchopneumonia or lobular pneumonia), and is asso-
ciated with malaise, pyrexia (temperature often >40°C),
rigors, vomiting, confusion caused by hypoxaemia (espe-
cially in the elderly) and tachycardia.
• Cough. This is dry at first but after a few days
purulent sputum is produced.
• Breathlessness. Blood passing through the affected
alveolar membranes is inadequately oxygenated so
that the PaO2 falls. Hyperventilation cannot
compensate for this hypoxaemia because blood
passing through the normal lung tissue is almost
saturated. The inflammation that occurs makes the
lung stiff and compliance is reduced with the result
that the effort of breathing is increased. Respiration
therefore becomes rapid and shallow.
• Pain. If inflammation spreads to the pleura there is a
sharp pain aggravated by taking a deep breath or by
coughing.
• Radiograph. Consolidation can be seen as an opacity,
especially in lobar pneumonia. There may also be
evidence of a pleural effusion.
• Auscultation. Bronchial breathing can be heard
(especially in lobar pneumonia) because the
consolidated lung tissue conducts the sounds of air
movement in the trachea. Whispering pectoriloquy
and increased vocal resonance can be heard. Wheeze
may be evident if bronchospasm is present.
Investigations
• Haematology. This may reveal a raised white blood
cell count.
• Biochemistry. Arterial blood gases should be
measured to reveal the extent of arterial hypoxaemia.
Chapter 6
• Microbiology. Sputum should be sent for Gram
staining to identify the causative organism (e.g.
S. pneumoniae) and to identify which antimicrobial
agents are sensitive to the organism.
• Pleural aspiration for culture. This should be
considered if the pneumonia is complicated by a
pleural effusion.
Prognosis
The outcome depends on predisposing factors, the viru-
lence of the bacteria, and the age and general fitness of the
patient. Improvement starts within 3–4 days of the patient
having antibiotics and within 10 days the sputum should
be less in quantity and mucoid in nature – by which time
the patient begins to feel better. In an otherwise fit person,
the radiograph should be clear in six weeks.
Generally, lobar pneumonia resolves and the patient
recovers, particularly in people who are generally fit and
are between the ages of 20 and 50 years. Bronchopneu­
monia is more serious, is often secondary to other prob-
lems and may be the terminal illness in patients who are
elderly. The disease may be fatal in the very young
because the secretions readily block the narrow, under-
developed airways.
Management
• Antibiotics are given to control infection. Specimens
of sputum should be sent for culture and sensitivity
as soon as possible to confirm or alter antibiotic
therapy.
• Adequate fluids must be taken to ensure fluid
balance.
• Analgesics are given to relieve pleuritic pain.
• Oxygen therapy may be necessary and blood gases
should be monitored regularly.
• Bed rest at home may be sufficient, but an acutely ill
patient should be admitted to hospital.
Complications
Possible complications of pneumonia are:
• spread to other lung areas;
• delayed resolution because of the wrong antibiotic
being given, poor compliance with medication or
bronchial obstruction (e.g. as a result of carcinoma);
• pleural disease resulting in pleural effusion or
empyema – this will require an intercostal tube and
drainage (possibly surgical drainage) and antibiotics
if an empyema is evident;
• lung abscess – this will cause a swinging pyrexia and
will require antibiotics;
• cardiac failure;
• septicaemia;
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 Tidy’s physiotherapy
• pneumococcal meningitis;
• pneumothorax – this is particularly associated with
S. aureus pneumonia and will require intercostal
tube drainage;
• deconditioning caused by malaise.
Physiotherapy in pneumonia
Physiotherapy is indicated when the inflammation has
begun to resolve. The aims of treatment are:
• to reduce bronchospasm (if present) and to clear
lung fields of secretions;
• to gain full re-expansion of the lungs;
• to regain exercise tolerance and fitness.
Clearing lung fields
Sputum clearance techniques may be indicated if there is
evidence of excessive secretions; however, routine chest
physiotherapy is not always indicated (Yang et al. 2010).
Humidification may be necessary to moisten secretions.
The method will vary according to the severity of the
illness and may be by nebuliser or IPPB. Clapping, shaking
and breathing exercises may all be necessary in a postural
drainage position appropriate to the area of the lung
affected if there is evidence of excess secretions. Sometimes
suction is required for the very ill patient who cannot
cough or expectorate. If there is an underlying bronchos-
pasm then a bronchodilator may be given.
Re-expansion of the lungs to improve ventilation
Positioning should be used to increase ventilation to the
affected area.
Exercise tolerance and fitness
As soon as possible, the patient should be mobilised and
start walking short distances which are progressively
increased in length.
Pleurisy
Definition
Pleurisy is a process whereby inflammation occurs on the
visceral and parietal pleura which come into direct
contact with each other to cause pain.
Aetiology and pathological changes
Pleurisy may also be secondary to tuberculosis or lobar
pneumonia. Infection or irritation of the pleura causes
inflammation and vascular congestion. A fibrinous exudate
is formed within the pleural cavity and the pleural surfaces
112
are roughened. The inflammation may resolve or develop
into a pleural effusion (see below), depending upon any
underlying conditions. When resolution occurs, fibrin laid
down within the exudate tends to form adhesions between
the two layers of the pleura.
The causes of pleurisy are:
• viral infection (the most common cause);
• pulmonary infarction;
• bronchial carcinoma;
• pneumonia;
• autoimmune rheumatic diseases (e.g. systemic lupus
erythematosus, rheumatoid arthritis).
Clinical features
• Pleuritic pain. This is a result of the movement of the
inflamed pleural membranes during inspiration. The
pain is sharp (knife-like), severe and related to
movement of the chest (e.g. deep inspiration or
coughing). It is usually well-localised to the area of
the chest under which the pleural irritation lies.
Irritation of the diaphragmatic pleura, however,
causes pain sensation via the phrenic nerve and this
is often referred to the tip of the shoulder.
• Pleural rub. There is a creaking or grating sound
heard through a stethoscope on both inspiration and
expiration. It is localised to the affected area. This
disappears if an effusion develops.
• Cough. Coughing may be present if respiratory
infection is the cause.
• Radiograph. The diaphragm may be raised on the
affected side.
• Other clinical signs. Tachycardia and pyrexia may be
present depending on associated conditions.
Investigation and treatment
Haematology shows a high white cell count if infection is
present. Identification and treatment of any underlying
conditions is essential. Analgesics are given to relieve pain,
and sedative linctus possibly reduces coughing. Rest is
important to allow the inflammation to subside and to
minimise the pain.
Physiotherapy in pleurisy
Physiotherapy is usually inappropriate in the early stages.
During the recovery stage, however, the aims are:
• to regain full thoracic expansion;
• to regain exercise tolerance;
• to mobilise the thorax.
General deep breathing exercises and early mobility
exercises, such as sitting with trunk bending side to
side and walking are important to regain mobility of the
thorax and thoracic spine, as well as increasing thoracic
expansion.
 Management of respiratory diseases
Pleural effusion
Definition
Pleural effusion is an excessive accumulation of fluid in
the pleural cavity.
Aetiology
Pleural effusion is often secondary to conditions such as:
• malignancy of the lungs or bronchi;
• pneumonia;
• tuberculosis;
• pulmonary infarction;
• bronchiectasis;
• lung abscess;
• blockage of lymph vessels;
• rupture of blood vessels;
• left ventricular failure.
Pathological changes
Fluid accumulates in the pleural cavity, the composition
of which varies according to the underlying cause. The
fluid may be reabsorbed naturally or removed by surgical
intervention. As the pleural layers come together they may
become adherent owing to organisation of fibrin if the
fluid contains plasma proteins.
Fluid may accumulate in the pleural cavity as transudate
or exudate. Transudate occurs when there is an increased
pulmonary capillary pressure (as in congestive cardiac
failure) or a decreased osmotic pressure (as in hypoprotei-
naemia associated with malnutrition) across the pleural
membrane. Exudate occurs when there is inflammation
resulting in increased permeability of capillaries and
visceral pleura together with impaired lymphatic
reabsorption (as in pneumonia or malignancy).
Exudate is cloudy with a high protein content, in con-
trast to transudate which is clear with a low protein
content. Consequently, exudate tends to become consoli-
dated whereas transudate can be reabsorbed if the under-
lying condition is treated.
Clinical features
• Breathlessness. The pressure of fluid reduces lung
expansion.
• Cyanosis. This may be present in a large effusion.
• Pyrexia. This is usually associated with infection.
• Lethargy. The person complains of a lack of energy.
• Pain. The person complains of pain.
• Thorax. Thoracic expansion is restricted on the
affected side.
Chapter 6
Investigations and treatment
A fluid level can be identified on X-ray. There is a stony
dullness on percussion over the fluid. Breath sounds are
absent over the effusion (>500 mL of fluid), although
bronchial breathing may be heard just above the effusion.
Small effusions (220–500 mL) are revealed by chest
radiography.
If the fluid does not become reabsorbed naturally, then
it should be aspirated (drained surgically). Oxygen therapy
may be necessary.
Physiotherapy in pleural effusion
The aims of physiotherapy are:
• to prevent the formation of disabling adhesions
between the two layers of pleura;
• to obtain full expansion of the affected lung;
• to increase ventilation of the lungs;
• to increase exercise tolerance following immobility.
The treatment must be modified to take into account
any underlying condition. Following aspiration, breathing
exercises should be given to encourage localised expansion
of the affected side.
If the patient has difficulty in localising the expansion,
it may be helpful to lie on the unaffected side over a firm
pillow to help stretch the affected side. Breathing exercises
may also be practised in this position several times a day.
When the patient has regained lung expansion, the treat-
ment programme should be expanded to include mobili-
sation of the patient and to increase exercise tolerance.
Some malignant pleural effusions may require a pleu-
rodesis – the insertion of a powder such as tetracycline
into the pleural cavity
Empyema
Definition
Empyema is a collection of pus in the pleural cavity.
Aetiology
The condition of empyema usually arises secondary to
pre-existing lung disease, such as bacterial pneumonia,
tuberculosis, lung abscess or bronchiectasis. The most
common cause is direct spread of infection into the pleural
space in a patient with pneumonia caused by S. pneumo-
niae. It may also arise as a result of a stab wound or as a
complication of thoracic surgery.
Pathological changes
Infected material enters the pleural cavity. Both layers of
pleura become covered in thick inflammatory exudate
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 Tidy’s physiotherapy
within which fibrous tissue is laid down. As this fibrous
tissue contracts it acts as a physical barrier to lung expan-
sion. The pressure of the fibrous tissue on the pus may
cause rupture of the pleura and lung tissue and the pus
may then be coughed up. Alternatively, an abscess may
form. Healing occurs when the pus has been surgically
removed or the infection has been overcome by the
patient’s natural antibodies, assisted by antibiotics. The
layers of the pleura come together and adhesion formation
may take place, restricting lung movement.
Clinical features
These include:
• pyrexia;
• lassitude and loss of weight;
• tachycardia;
• dyspnoea;
• pleuritic pain severe at first then decreasing in
severity;
• diminished thoracic movements.
There may be a history of pneumonia or other associ-
ated condition.
Investigations and treatment
On X-ray, the empyema can be seen as a D-shaped shadow,
the straight line of the D being on the lung surface. Pleural
aspiration or tap will confirm the diagnosis as the sample
is often thick and purulent, and may be foul-smelling.
Pleural fluid cytology will reveal an exudate with pus cells
and organisms.
Antibiotics are given to combat infection. Aspiration
through a needle inserted into the cavity may remove suf-
ficient pus to relieve the condition, but continuous under-
water drainage may be necessary. Rib resection may be
indicated if the effusion is very thick or loculated.
If the condition results in fibrosis of the pleura which
severely limits lung expansion, then a rib resection may
be performed and the pleura stripped off the lung
(decortication).
The prognosis depends on the cause, but untreated
infection can make the patient very ill from toxins
absorbed into the bloodstream (toxaemia).
Physiotherapy in empyema
The aims are:
• to minimise adhesion formation within the pleura;
• to regain full lung expansion;
• to clear the lung fields;
• to maintain good posture and thoracic mobility;
• to improve exercise tolerance.
If the patient has a chest drainage tube inserted, the
physiotherapy is similar to that following a thoracotomy.
114
Good posture should be encouraged whenever physiother-
apy is being given. The tendency is for the patient to
protect the affected side, by side-flexing to that side. There-
fore, the patient should be taught to take weight evenly on
both buttocks, to keep the shoulders level and to practise
stretching to the opposite side from the lesion, as well as
stretching backwards.
Breathing exercises to expand the lung on the affected
side need to be carried out three or four times daily.
Postural drainage may be indicated to clear the lungs if
secretions are accumulating.
As the patient recovers, general leg, arm and trunk exer-
cises should be taught. Walking should begin as soon as
possible with breathing control practised over progres-
sively longer distances, and going down (then up) stairs
incorporated. As the patient regains lung expansion, the
treatment programme should be expanded to increase
exercise tolerance.
Pneumothorax
Definition
Air collects between the visceral and parietal pleura. Air
in the pleural space will allow the lung to move away
from the chest wall and the lung will partially deflate.
There are two types of pneumothorax, spontaneous
(which may be secondary to an underlying disease) and
traumatic.
Spontaneous pneumothorax
This can occur at any age but is most common in young
men (a ratio of 6 : 1) who are otherwise apparently healthy.
It may also be associated with emphysema and chronic
bronchitis in men over 50 years of age, result from other
underlying disease or be associated with mechanical ven-
tilation. These spontaneous causes may be summarised as:
• airflow limitation caused by asthma or bullous
emphysema;
• positive pressure ventilation, particularly with the
use of positive end-expiratory pressure (PEEP);
• infections (e.g. Staphylococcal pneumonia,
tuberculosis);
• CF;
• Marfan’s syndrome.
Traumatic pneumothorax
A traumatic pneumothorax may be caused by:
• penetrating injury to the chest (e.g. by stab or bullet
wound);
 Management of respiratory diseases
• non-penetrating injury to the chest wall (e.g. impact
of a road traffic accident involving the chest);
• during the insertion of an intravenous (e.g.
subclavian) line;
• during surgery to the chest wall;
• during pleural aspiration or biopsy.
When the chest wall remains intact, the condition is
termed a closed pneumothorax, but if the chest wall is
opened following the trauma the term used is open pneu-
mothorax. In the presence of an open wound, the emer-
gency treatment is the application of a large dressing pad
over the chest wall.
Pathological changes
As air escapes into the pleural cavity and reduces the sub-
atmospheric pressure (i.e. less negative) the lung collapses.
The hole in the pleura closes, the air becomes absorbed
and the lung gradually re-expands. Sometimes this does
not happen and the hole in the pleura becomes like a
valve. Air then enters the pleural cavity on inspiration
but cannot escape during expiration. The lung remains
collapsed and, as air accumulates in the pleural cavity
and the pressure increases, there is displacement of the
heart together with compression of the other lung and
great vessels. This is termed a tension pneumothorax and
has to be treated as an emergency by needle aspiration
and thereafter by insertion of a drain connected to an
underwater seal.
Clinical features
The onset is often sudden with severe chest pain and pro-
gressive breathlessness. There is diminished chest move-
ment unilaterally and an absence of breath sounds often
over the apex of the affected side.
Other clinical features may be related to the underlying
pathology (e.g. emphysema). In a patient with known
lung disease a pneumothorax should always be considered
if the patient becomes more breathless for no apparent
reason.
Subcutaneous emphysema may develop at the time of
the pleural air leak or following the insertion of an inter-
costal drain when air may track into the subcutaneous
tissues. Subcutaneous air results in a crackling sensation
on palpation.
Investigations and treatment
The chest X-ray shows absence of lung markings and the
edge of the collapsed lung can be seen. This will confirm
the diagnosis. Inspiratory and expiratory radiographs will
help define the visceral pleura where there is a small
pneumothorax.
A small pneumothorax requires no treatment apart
from a few days bed rest until it resolves. A large
Chapter 6
pneumothorax (i.e. more than 25% of the pleural space is
filled with air) is treated by needle aspiration or by an
intercostal drain which connects the pleural cavity to a
drainage bottle creating an underwater seal. The drain is
removed when there are no more bubbles in the drainage
bottle – indicating that the pleural cavity is free of air.
Surgery is indicated for a recurrent pneumothorax. Pleu-
rodesis comprises the insertion of a powder into the
pleural cavity. This acts as an irritant to the pleural surfaces
causing them to adhere to each other. Pleurectomy is the
removal of the parietal pleura from the chest wall leaving
a raw surface to which the visceral layer sticks. A hole in
the visceral pleura may have to be stitched.
Physiotherapy in pneumothorax
A patient who has an underwater drainage system requires
expansion breathing exercises to re-expand the lung. Also,
full-range shoulder movements are necessary to maintain
shoulder, shoulder girdle and thoracic mobility. This treat-
ment is generally given 3–4 times daily until the drain is
removed.
Following pleurodesis, expansion breathing exercises
are essential to ensure that when the adhesions form
between the layers of the pleura the lung is fully expanded.
The patient must be taught to practise expansion breathing
exercises so that thoracic mobility is maintained, other-
wise there may be sharp pleuritic pain if the intrapleural
adhesions become too contracted. If the lung does not
re-expand within 36 hours then a second operation is
required. Physiotherapy after a pleurectomy follows the
same principles as for any thoracotomy.
Acute respiratory distress syndrome
A catastrophic event can, either directly or indirectly, cause
damage to the pulmonary epithelium or the alveolar
capillary membrane. Acute respiratory distress syndrome
(ARDS) is, therefore, the respiratory manifestation of a
systemic condition which appears within 12–48 hours
after the initial triggering event.
Definition
ARDS is a severe and acute form of respiratory failure
precipitated by a wide range of catastrophic events,
including shock, septicaemia, major trauma, or aspiration
or inhalation of noxious substances (Bernard et al. 1994).
Examples of triggering events are: pulmonary aspira-
tion; severe burns with or without inhalation injury;
disseminated intravascular coagulation (a coagulation
defect caused by clotting abnormalities); cardiopulmo-
nary bypass; severe trauma; massive blood transfusion;
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 Tidy’s physiotherapy
near-drowning; pre-eclampsia; septicaemia; amniotic fluid
embolism (substances entering the maternal circulation
usually following a vigorous labour); pancreatitis; and fat
embolism resulting from the fracture of (long) bones.
Pathological changes
Activated neutrophils are thought to release a number of
vasoactive mediators that damage the integrity of the alve-
olar membrane. As a result of increased endothelial per-
meability within the alveolar–capillary membrane, fluid
moves from the pulmonary capillaries into the gas
exchange areas of the lung. This results in alveolar oedema
and extravasation of inflammatory cells. The pulmonary
oedema is therefore said to be non-cardiogenic because
there is normal hydrostatic pressure in the pulmonary
vasculature (unlike left ventricular failure when this is
raised). As this acute phase progresses, there is increasing
congestion in the capillaries. The loss of functioning
alveoli results in severe hypoxaemia and respiratory
failure.
Clinical features
The defining features of ARDS are:
• severe refractory (resistant to treatment) hypoxaemia;
• the presence of pulmonary oedema with normal
hydrostatic pressure in the pulmonary vasculature;
• the appearance of diffuse bilateral pulmonary
infiltrates on chest X-ray;
• a falling pulmonary compliance (<50 mL/cmH2O).
Increasing breathlessness is evident which, left un­­
treated, may lead to acute tachypnoea (>20 breaths per
minute). There is evidence of the appearance of diffuse
bilateral pulmonary infiltrates on chest X-ray, and wide-
spread wheezes and crackles on auscultation. Despite
oxygen, the disease usually progresses to a state of severe
respiratory failure, which requires the support of me­­
chanical ventilation. The lungs become progressively
stiffer and adequate oxygenation and ventilation becomes
more difficult.
Investigations and treatment
On blood gas analysis the PaO2 is reduced to critical
levels. If this is not corrected the PaCO2 may begin
to rise.
Any underlying pathological cause is treated. Adequate
ventilatory support will be necessary, which may include
high inspired oxygen, IPPV and the application of PEEP
to restore adequate function by allowing for the recruit-
ment of hypoventilated alveoli. This will result in an
improved PaO2. High levels of oxygen may be used ini-
tially to reduce a dangerous hypoxaemia, but as oxygen is
toxic at high concentrations (causing further damage to
116
the alveolar membrane) this should be reduced to a level
that will give an adequate PaO2. Although the application
of PEEP in this condition has been standard practice for
over two decades, over-distension of lung tissue may result
in baro- and volu-trauma with the development of pneu-
mothorax and subcutaneous emphysema (Montgomery
et al. 1985).
Complications
Nosocominal pneumonitis is a common complication
in patients with ARDS on prolonged mechanical ventila-
tion and is directly related to oropharyngeal colonisation
of Gram-negative bacilli – the stomach being one of
the possible reservoirs of these microorganisms (Driks
et al. 1987). The loss of mucosal integrity and clearance
mechanisms are predisposing factors which lead to sec-
ondary infection and may contribute to worsening gas
exchange.
Hence, adequate removal of retained bronchial secre-
tions by chest physiotherapy techniques is an integral part
of the management of these patients.
Prognosis
A substantial number of studies have now confirmed that
the primary cause of death in patients with ARDS is
not the inability to oxygenate arterial blood adequately
but rather the result of the development of multiple
organ dysfunction and failure (MOF) caused by poor
tissue oxygen extraction and altered tissue bloodflow
(Montgomery et al. 1985; Fowler and Goldman 1990).
These manifestations are associated with a high mortality
rate. Approximately 30–60% of patients with ARDS die,
despite increasing awareness of the mechanisms of acute
injury and the introduction of novel forms of therapy and
support (Bernard et al. 1994).
Physiotherapy in ARDS
The aims of physiotherapy are:
• removal of retained secretions if these are present;
• passive/active movements in ventilated patients and
ambulation as soon as this is feasible.
Chest physiotherapy involves four principal manoeu-
vers: positioning to enhance removal of secretions and to
improve gas exchange; manual hyperinflation; endotra-
cheal suctioning; and manual techniques (which include
shakings and vibrations).
Passive and active exercises need to be performed regu-
larly while the patient’s mobility remains restricted during
the critical stages of their disease, in order to maintain the
mobility of joints and the extensibility of the soft tissues
(e.g. the muscles, tendons and ligaments). When possible,
the patient should be mobilised.
 Management of respiratory diseases
Fibrosing alveolitis
Definition
In fibrosing alveolitis the alveolar walls become
thickened, with an increase in type II pneumocytes and
macrophages. As the disease progresses the alveolar
walls fibrose and fibrosis spreads to the lung
parenchyma.
The aetiology of fibrosing alveolitis is unknown (in most
cases), although in some cases there is evidence of a pre-
existing specific disease. These may be autoimmune (e.g.
rheumatoid arthritis, systemic sclerosis) or gastrointestinal
(e.g. chronic active hepatitis, ulcerative colitis).
Clinical features
• Dyspnoea. There is an insidious onset of
breathlessness often accompanied either by a dry
unproductive cough or with little clear sputum.
• Auscultation. A typical feature is mid-to-late
inspiratory crackles, which are said to be ‘metallic’ in
nature.
• Finger clubbing. As the disease progresses most
patients develop gross finger clubbing.
• Cyanosis. This is caused by impaired gas exchange.
Investigations and treatment
Blood gases reveal a progressive hypoxaemia with hyper-
capnia evident late in the disease. The chest radiograph
will first show a ground-glass appearance, mainly in the
lower zones; as the disease progresses, this becomes dis-
crete and nodular. Transbronchial or open lung biopsy
shows interstitial and alveolar fibrosis. Lung function
tests reveal a restrictive deficit with reduced gas transfer
factor.
Chronic forms of fibrosing alveolitis are treated with
high doses of oral corticosteroids, although the value
of these has been recently investigated and shown to
be largely ineffective. Other immunosuppressive drugs
(e.g. cyclophosphamide) are sometimes used if the
alveolitis is associated with an autoimmune disease.
Long-term oxygen therapy (LTOT) should be considered
to correct hypoxaemia which leads to pulmonary hyper-
tension and the development of cor pulmonale. Heart–
lung transplantation may be considered in younger
patients.
The median survival time of patients with fibrosing
alveolitis is less than five years, although some patients
may live for much longer. In general, the earlier the onset
of the disease, the worse the prognosis.
Chapter 6
Physiotherapy in fibrosing alveolitis
Physiotherapy should be directed at teaching breathing
control and maintaining exercise tolerance as the patient
becomes deconditioned as a result of fatigue and shortness
of breath.
OTHER PULMONARY DISEASES
Lung abscess
Definition
A lung abscess is the localised formation of pus, usually
surrounded by a fibrous capsule, within lung tissue.
Antibiotics and improved anaesthesia have reduced the
incidence of lung abscess and the condition now tends to
occur secondary to bronchial carcinoma, particularly in
patients who are over 40 years.
Aetiology
A variety of bacteria may enter the lungs by one of the
following routes:
• through the air passages because of
bronchopneumonia or following inhalation of a
foreign body;
• through the open chest wall following a wound from
a knife stab or bullet;
• from the bloodstream;
• bronchial carcinoma – an abscess forms where
secretions accumulate distal to the tumour.
Pathological changes
The invading organisms cause inflammation of the lung
tissue. At the centre of the area there is necrosis of
lung tissue with liquefaction and suppuration. The area
becomes distended and fibroblasts lay down fibrous tissue
around the area until there is complete encapsulation. The
capsule contracts and the abscess bursts, resulting in the
production of foul-smelling sputum. Sometimes the pus
drains into the pleura, causing empyema, and if drainage
spills into adjacent lung tissue there is a danger of bron-
chiectasis. Toxins from the pus can be absorbed into the
bloodstream and there is then a danger of septicaemia.
Healing occurs with the formation of a fibrous scar.
Clinical features
There is malaise, fever, cough and dyspnoea. The cough is
irritable and unproductive at first but later it is productive
of foul-smelling sputum accompanied by a bad taste in
the mouth. The cough may be painful if the pleura are
117
 Tidy’s physiotherapy
inflamed. Haemoptysis and halitosis are further features.
Finger clubbing may become evident if the abscess
becomes chronic.
Investigations and treatment
Blood analysis may reveal an increased white cell count.
Cultures of sputum or lung aspirate will reveal the organ-
ism. A chest X-ray will show an area of cavitation within
the lung tissue, which may contain an air-fluid level.
Most lung abscesses will respond to large intravenous
doses of antibiotics to which the organism is sensitive.
Drainage of the abscess may be necessary via needle as­­
piration or a thoracotomy. If there is an endobronchial
obstruction caused by a foreign body, removal is essential.
Physiotherapy for a lung abscess
The site of the abscess is ascertained on the radiograph
and the patient is positioned accurately for 10–15 minutes
every 4 hours. Shaking is applied to the chest wall and
breathing exercises are taught to regain breath control after
coughing. Deep inspiration should not be encouraged
because the increase in negative pressure may move the
pus through healthy lung tissue.
It is important to adjust the patient’s position to obtain
maximum effective drainage and to ensure that precau-
tions are taken to avoid any danger of cross-infection.
Pulmonary tuberculosis
Definition
In pulmonary tuberculosis (TB) the bacillus
Mycobacterium tuberculosis causes irritation of the
mucous lining in the bronchioles or alveoli, and
inflammatory changes take place.
In 1882, Robert Koch isolated the tubercle bacillus, of
which there are two types: one human and one bovine.
Since then, the disease has been controlled by inoculation,
mass radiography, drugs and pasteurised milk; however,
TB is on the rise again, particularly in areas with a high
incidence of HIV/AIDS and poverty.
Key point
The lungs are not the only tissues to be affected by TB.
Types of TB other than pulmonary are: acute miliary (the
blood is affected, with spread of the disease to spleen,
liver, kidneys, meninges and lymph nodes); surgical TB;
bone or joint TB; lupus vulgaris (the skin is affected); and
TB adenoma (the lymph nodes are affected).
118
Aetiology and prevalence
Mycobacterium tuberculosis is spread by droplets during
coughing and sneezing, so that a person can be infected
from a patient’s sputum. The bacillus may be restrained
by the immune system, but never destroyed and may lay
dormant for a number of years. It may then be reactivated
in 5–10% of carriers.
TB is common worldwide and its incidence has increased
in the UK in recent years. The disease is still very common
in Africa and Asia. In Europe, the age group most com-
monly affected is middle age, but it also often occurs
in elderly men. In the UK, the disease occurs mainly in
the immigrant population from Ireland, Asia and the
West Indies.
Predisposing factors are the environment, poor hygiene,
overcrowding, lower socioeconomic groups, malnutrition,
smoking and alcoholism. Other factors are diseases such
as HIV/AIDS, diabetes mellitus, congenital heart disorder,
leukaemia, Hodgkin’s disease, long-term corticosteroids or
immunosuppressive drugs.
Pathology
The bacilli are ingested by leucocytes and then absorbed
by macrophages. More leucocytes form a barrier around
this collection of cells and the complete mass is known as
a ‘tuberculous follicle’. The centre of the area undergoes
necrosis and becomes soft and cheesy in consistency, the
process being known as ‘caseation’. This material may be
moved into a bronchus and coughed up leaving a cavity
behind. Fibroblasts lay down a capsule around the tuber-
cle in which calcium salts become deposited and healing
takes place.
Cavity formation and calcification are the features of TB,
with the calcified lesion remaining a potential source of
infection. The bacillus may be reactivated and cause post-
primary pulmonary TB. The danger then is that the disease
may spread to other areas of the lungs including the pleura
and through the bloodstream to other parts of the body.
Clinical features
These are:
• malaise, lassitude and irritability;
• loss of appetite and loss of weight;
• pyrexia and tachycardia;
• night sweats;
• productive cough – the bacillus can be cultured from
the sputum;
• haemoptysis;
• diminished respiratory movements with possibly
some dyspnoea;
• pain if there is pleural involvement.
Investigations
The chest X-ray shows cavity formation and calcification.
In children these clinical features may be present to a mild
 Management of respiratory diseases
degree and the disease can pass undetected. Other inves-
tigations are as follows.
• Haematology. The full blood count may show
anaemia.
• Immunology. The Mantoux test is usually strongly
positive in post-primary pulmonary TB, but is
frequently negative in miliary TB.
• Microbiology. Sputum culture will show tubercle
bacilli after 4–5 weeks of the primary infection.
Bacilli may be cultured from the bone marrow in
patients with miliary TB.
• Diagnostic imaging. In post-primary TB the chest
X-ray may demonstrate a pleural effusion or
pneumonia. A soft spreading apical shadowing is
strongly suggestive of TB. There is widespread
shadowing (i.e. small nodules 2–3 cm diameter) in
miliary TB.
Prevention
Vaccination with BCG (Bacille Calmette–Guérin) greatly
reduces the incidence of the disease and is offered to
schoolchildren in the United Kingdom. The vaccination
may be offered to people who might have contact with a
patient who has active TB, such as relatives, friends, teach-
ers, doctors, nurses and physiotherapists. Pasteurisation of
milk prevents transmission of the tubercle to humans
from cows.
Treatment
Drug therapy, together with rest, is the treatment for curing
TB. Anti-TB drugs used are rifampicin, isoniazid, etham-
butol and para-aminosalicylic acid; these must be taken
every day for up to 18 months. The antibiotic streptomycin
may also be prescribed. Multiple drug regimens are used
in the treatment of resistant strains. Uncomplicated pul-
monary TB is treated with a relatively short course (i.e. 6–9
months). If other organs are involved a longer course of
treatment may be necessary (e.g. 18 months for bone
disease). Multidrug resistant TB (MDR-TB) and extensively
drug-resistant TB (XDR-TB) is becoming an increasing
problem as a result of poorly administered drug regimes,
or interrupted or inadequate therapy.
Surgery is appropriate only in a very small proportion
of patients. If a patient has a resistant tubercle a lobectomy
may be performed, but the patient must still be on a
drug regimen. The prognosis is good if the patient is not
immunosuppressed.
Physiotherapy in pulmonary tuberculosis
Once the patient is ambulant, a graded programme of
exercises may be required. If it is necessary to give breath-
ing exercises, the physiotherapist should stand behind the
patient to avoid droplet infection as the patient coughs.
Chapter 6
Sputum must be disposed of very carefully so that cross-
infection is prevented.
Bronchial and lung tumours
Key point
Tumours may be benign or malignant. The majority are
malignant growths which may be primary or secondary.
Tumours arising within the lung (bronchial carcinomas)
usually originate within the bronchi, while those that
spread from other primary sites (e.g. breast, gastrointesti-
nal tract) tend to develop in the lung tissue or the pleura.
In the UK, there are approximately 35,000 deaths from
carcinoma of the bronchus each year. Men are more com-
monly affected than women, although the incidence in
women is increasing.
Causative factors
People who smoke tobacco have a much greater risk of
developing a malignant tumour than those who do
not. The risk depends upon the number of cigarettes
smoked, the age of starting to smoke and the timespan of
smoking. The concept of pack-years is described at the
beginning of this chapter.
The disease is more prevalent in urban dwellers than in
rural dwellers. There is also evidence that exposure to
carcinogens, either at work or leisure, can result in the
development of the disease. Working with radioactive
materials, nickel, uranium, chromates or industrial asbes-
tos is associated with an increased risk of bronchial
carcinoma.
Pathology
The majority of tumours originate in the large bronchi and
spread by direct invasion of the lung, chest wall and medi-
astinal structures. The tumour grows to occlude the lumen
of the bronchus and then atelectasis distal to the growth
will occur. There are various types (Table 6.5).
Clinical features
Seventy per cent of patients present with local symptoms.
The onset is insidious and the clinical features may present
in a variety of ways.
• Cough. This is the most common feature and is often
ignored by the patient who may associate it with
smoking. Initially, the cough is dry and irritating but
may become productive if infection occurs in
accumulated secretions.
119
 Tidy’s physiotherapy

Table 6.5  Histology of bronchial tumours • Cerebral metastases. These may cause stroke,
headaches and epilepsy.
Histology Proportion Characteristics
• Bone metastases. The patient may present with spinal
cord compression, pathological fracture and bone
of bronchial
pain.
cancers (%)
• Liver metastases. The patient may present with
Squamous cell 50 Locally invasive, jaundice and hepatomegaly (an enlarged liver).
cavitation Non-metastatic presentations include finger clubbing,
sometimes occurs and neuromuscular and endocrine abnormalities.
Oat/small cell 25 Small lung
primary, rapidly Investigations
dividing,
metastasise early • Chest radiograph. This is essential for any patient
presenting with haemoptysis and will demonstrate
Large cell 12 Intermediate over 90% of lung tumours. Small tumours or those
between close to the hilum may be missed.
squamous and • CT scanning. This may be used to identify smaller
oat/small cell lesions. It may also be used to assess suitability for
Adenocarcinoma 12 Slowly growing, surgery by demonstrating metastatic spread.
metastasises late, • Histopathology. Sputum culture may have evidence of
often peripheral tumour cells. Three (early morning) samples should
lung tumours be obtained.
• Bronchoscopy. This is used to obtain tissue samples
Miscellaneous 1 For example, and may also be used to assess operability.
alveolar oat cell
• Percutaneous needle biopsy. This may be useful
carcinoma
for the histological assessment of a peripheral
tumour.
• Pleural aspiration and biopsy. These may be used for
• Haemoptysis. There are recurrent small spots of blood the patient who presents with a pleural effusion.
in the sputum.
• Dyspnoea. This is highly variable and may be severe Treatment
when there is pulmonary collapse or pleural
effusion. The appropriate treatment may be surgery, chemotherapy
• Pain. Dull, deep-seated pain is common but it may and/or radiotherapy. Essentially, drug therapy is to
be pleuritic in nature or intercostal when there is rib relieve symptoms and includes analgesics, antibiotics and
disease. anti-emetics.
• Malaise and weight loss. These are associated with late • Surgery. This involves removing the lobe or lung. It is
stages of the disease. possible only while the tumour remains localised
• Secondary concomitant disease. Pneumonia or lung and in the absence of metastases. Stenting is another
abscess may arise as a result of a tumour. option for localised disease.
• Hoarseness of the voice. This is a result of left recurrent • Chemotherapy. Cytotoxic drugs are used
laryngeal nerve involvement by tumour of the left with increasing regularity. Results are mixed but
hilum. anaplastic tumours tend to respond to this type of
• Stridor. This is a result of narrowing of the trachea or treatment.
main bronchus. • Radiotherapy. This is used symptomatically
• Facial swelling. This is a result of superior vena caval particularly to relieve pain and obstruction.
obstruction following invasion of the mediastinum. • Laser phototherapy. This can be used to treat persistent
• Arm and shoulder pain. These are caused by tumour at localised disease.
the apex of the lung (Pancoast tumour) invading the The prognosis depends upon the type of tumour, but
brachial plexus. the overall length of survival is around one year. Surgery
can prolong life in some patients. In the terminal
stages attention should be paid to the patient’s general
Metastases well-being and mental state. Some patients benefit
Metastases are common in patients with bronchial carci- from hospice care and adequate opiate analgesia is essen-
noma and may include the following. tial for pain.

120
 Management of respiratory diseases
Physiotherapy for bronchial and
lung tumours
Physiotherapy may be related to three aspects of manage-
ment of the disease.
• Pre- and postoperative physiotherapy is essential for
patients who have a lobectomy or pneumonectomy.
• During and after radiotherapy, when the tumour
begins to decrease in size, the patient will begin to
expectorate sputum. Positioning and the ACBT
should be used for sputum clearance. Percussion and
vigorous shaking should not be used as there is a
danger of pathological fractures in ribs or vertebrae
in which metastases may be developing. Nor should
shaking them be used in the presence of
haemoptysis.
• During the terminal stage of the disease, where
accumulation of secretions is causing distress,
modified postural drainage and vibrations with
breathing exercises may help to make the patient
more comfortable. If coughing is ineffective, suction
may have to be used. An active daily programme
which fits the patient’s requirements may need to be
devised, in which case the physiotherapist works in
close collaboration with the healthcare team.
RESPIRATORY FAILURE
Definition
Respiratory failure denotes reduction of function of the
lungs as a result of lung disease or a skeletal or
neuromuscular disorder resulting in pump failure. It is
defined in terms of the gas tensions (pressures) in the
arterial blood (Roussos and Koutsoukou, 2003).
Normal arterial oxygen and carbon dioxide pressures
(PaO2 and PaCO2) are 13.0 kPa (97 mmHg) and 6.1 kPa
(46 mmHg) respectively. There are two types of respiratory
failure.
• Type 1: A PaO2 of less than 8.0 kPa (60 mmHg) is
associated with a PaCO2 which is either normal or
below 6.7 kPa (50 mmHg).
• Type 2: A PaO2 of less than 8.0 kPa (60 mmHg) is
associated with a PaCO2 raised above 6.7 kPa
(50 mmHg).
Causes of type 1 respiratory failure
Lung disease results in hypoventilation of the alveoli
leading to a ventilation/perfusion mismatch. The blood
Chapter 6
supply may be normal but there is inadequate oxygen
uptake from the affected alveoli. There may be disruption
in blood supply to oxygenated alveoli, or shunt, resulting
in obstruction of passage of oxygen from the lungs into
the blood in the affected area. Diseases associated with
this type are early chronic bronchitis and emphysema,
pneumonia, asthma, acute pulmonary oedema, pulmo-
nary embolism, pulmonary fibrosis and ARDS.
Causes of type 2 respiratory failure
Because of failure of the skeletal or neuromuscular com-
ponents of the respiratory system there is loss of the pump
mechanism essential for ventilation of the lungs as a
whole. Therefore, there is a reduced tidal volume or a
reduced respiratory rate, leading to a rise in PaCO2 and
a fall in PaO2. Disorders associated with this type are:
• respiratory muscle fatigue secondary to acute
exacerbation of lung disease, such as advanced
chronic bronchitis and emphysema;
• status asthmaticus;
• direct denervation to respiratory muscles which may
occur in cervical cord injuries;
• neuromuscular disorders affecting the nerves
innervating muscles of respiration or the muscles
themselves, e.g. muscular dystrophy, myasthenia
gravis and polyneuropathies;
• mechanical disorders affecting the thorax, such as
kyphoscoliosis or a crush injury to the chest;
• central respiratory drive dysfunction, e.g. head
injuries.
Clinical features
• Type 1 owing to hypoxaemia: There may be
dyspnoea, restlessness, confusion, central
cyanosis, tachycardia, renal failure, pulmonary
hypertension.
• Type 2 owing to hypercapnia: There may be flapping
tremor of the hands, confusion, headache, warm
peripheries, tachycardia. Dyspnoea occurs initially
but the person may become drowsy and comatose
if PaCO2 is allowed to rise.
Treatment
Key point
The diagnosis cannot be accurate until arterial blood
gases have been measured. Treatment must be directed
towards treating the underlying cause.
121
 Tidy’s physiotherapy
In type 1 respiratory failure the main problem is the
hypoxaemia, so it is important to raise the PaO2 by giving
oxygen therapy, which should be given in sufficient
amounts to correct the hypoxaemia.
In type 2 respiratory failure the hypoxia needs to be
reversed, but the hypercapnia also needs to be addressed.
Support via invasive or noninvasive ventilation may be
indicated in order to increase tidal volumes and ‘blow off’
excess CO2.
Physiotherapy in respiratory failure
Type 1 failure
It is vital to clear the lung fields of secretions – if present.
If the patient is spontaneously breathing, positioning
and ACBT can be used with manual techniques to loosen
secretions. If the patient is too weak to cough, a cough
insufflator-exsufflator may be used to enhance the cough;
however, suction may have to be used. If bronchospasm
is evident, a bronchodilator (e.g. salbutamol) may be
given in combination with oxygen therapy. Continuous
positive airway pressure may be required to increase the
functional residual capacity (FRC) and optimise gas
exchange. If severe, invasive mechanical ventilation may
be indicated. A bronchodilator may be administered
through the ventilator and shakings and vibrations should
be performed with manual hyperinflation. Suction will be
via the endotracheal tube. All treatment is monitored by
regular peripheral oxygen saturation measurement or
blood gas analysis.
Type 2 failure
Again, it is necessary to raise the PaO2 and this is achieved
by oxygen therapy using a Ventimask delivering 24%
oxygen. If this is not sufficient to raise the PaO2 the Ven-
timask may be changed to one delivering 28% oxygen,
provided the PaCO2 is not rising further. If the PaCO2
starts to rise this is indicative of hypoventilation and wors-
ening of type 2 respiratory failure, usually because the
patient is becoming exhausted. NIPPV may be indicated,
which will augment tidal volume and increase the FRC.
If hypercapnia is severe and NIV is contra-indicated
the patient may require invasive mechanical ventilation.
Physiotherapy follows similar principles to that for
type 1 failure.
Chronic hypercapnia/acute-on-
chronic type 2 respiratory failure
This is seen most frequently in patients with COPD. The
pH will be within normal limits (owing to metabolic com-
pensation); however, the PaCO2 will be raised above
normal. In type 2 respiratory failure there is a danger
of reducing the respiratory drive which is normally
122
dependent on the anoxic state of the blood stimulating
the chemoreceptors in the carotid and aortic arteries. If too
much supplemental O2 is provided the danger is that the
patient’s respiration slows, or stops, and the PaCO2 rises,
resulting in confusion and coma. A Ventimask giving 24%
or 28% inspired oxygen may be applied (see the section
on oxygen therapy in COPD).
A patient with chronic hypercapnia may present with
acute-on-chronic respiratory failure with a worsening pH
and rising PaCO2. Signs and symptoms may include
worsening dyspnoea, increasing confusion and respiratory
arrest. These patients should be treated the same way as a
patient presenting with acute type 2 respiratory failure.
Respiratory failure in  
neuromuscular disease
Respiratory failure and dysfunction are common in many
chronic neurodegenerative conditions, for example multi-
ple sclerosis (Gosselink et al. 1999) and Huntington’s
disease (Sorensen and Fenger 1992). As these diseases
progress the patient may lose his/her ability to cough
effectively. Physiotherapy management should be aimed
at the removal of retained secretions. This should focus on
increasing lung volumes in order to create flow rates
sufficient to mobilise and expectorate secretions from
the airways. This may be achieved by use of NIV or
by a cough-assist device. When expiratory flows remain
insufficient, manually-assisted cough techniques can be
used to augment patients’ cough.
SLEEP AND BREATHING
It is important to consider what happens to breathing
during sleep, as problems with breathing may initially
become apparent during sleep before progressing to devel-
opment of daytime respiratory failure.
Normally, during non-rapid eye movement (REM) sleep
ventilation is decreased compared with ventilation when
awake. During REM sleep breathing becomes irregular
with episodes of severe hypoventilation. General muscle
tone reduces, including a reduction in tone to the muscles
that dilate the pharynx resulting in narrowing of the
pharynx and an increase in upper airway resistance. Ven-
tilatory responses to hypoxia and hypercapnia are reduced
during REM sleep and in non-REM sleep to a lesser degree.
The response of respiratory muscles to signals from the
respiratory centre in the brain is reduced during sleep;
however, the diaphragm is less affected than the accessory
muscles. In normal people there is no clinically significant
deterioration in arterial blood gas values; however, pro-
found hypoxaemia may occur in patients with respiratory
insufficiency which may eventually result in daytime res-
piratory failure (McNicholas 2000; Gay 2004).

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 Chapter
Adult spontaneous and conventional
mechanical ventilation
Sue Pieri–Davies, Helen Carruthers, with a Contribution from Melanie Reardon
INTRODUCTION
This chapter focusses on the ventilatory aspects of the
patient in respiratory failure. A basic understanding of all
major systems is essential when considering the physio-
therapeutic requirements of the ventilated adult, as the
initial assessment necessitates identification of the under-
lying cause. The aim of intervention will then either be
correction where possible and/or alleviation of respiratory
symptoms, such as breathlessness, re-inflation, reduction
in the work of breathing and sputum retention.
The detailed undergraduate training in anatomy and
physiology places the physiotherapist in an excellent posi-
tion to manage the respiratory and rehabilitation needs
of such complex patients. However, in order to enable
an applied approach to the assessment (incorporating
problem-solving) findings and required management, as
is the requirement in the emergency on-call duty setting,
it is essential to understand the basics of respiratory
mechanics in the spontaneously breathing individual.
This section, focussed on conventional mechanical ven-
tilation, should be read in conjunction with Chapters 6
and 8. It is beyond the scope of a single chapter to detail
all appropriate systems, the numerous conditions and
causes of ventilatory failure, the concept and uses of non-
invasive ventilation, and the more specialised area of
domiciliary ventilation. A more detailed knowledge of
these subjects can be obtained through further private
study of the recommended texts and websites provided at
the end of this chapter.
SPONTANEOUS VENTILATION
The basics of respiratory mechanics in the spontane-
ously breathing individual must be understood, as the
7 
application/weaning of mechanical ventilatory support/
control will have a direct impact upon respiratory capac-
ity. An ability to recognise and interpret deviations from
the normal is of prime importance in maximising and
maintaining efficient spontaneous respiratory function,
particularly during an episode of critical illness.
The respiratory muscles
The respiratory muscles consist of two main groups: the
primaries (consisting mostly of the diaphragm and inter-
costals) and the accessories (comprising mostly of the
scaleni, abdominals and sternocleidomastoids). It is also
important to remember the effects upon the oxygenation
status and the balance of the blood pH with increasing
metabolic demands should the recruitment of other addi-
tional muscles, for example the facial muscles with pursed-
lip breathing, and the shoulder girdle and arm fixators, be
required during times of respiratory distress/dysfunction.
The primaries’ main role is that of ventilation. The acces-
sories have other functions, but are recruited to facilitate
ventilation when required. Normally, the respiratory
muscles have both ventilatory and non-ventilatory motor
functions, for example the diaphragm acts as the primary
respiratory muscle, responsible for generating approxi-
mately 60–70% of the tidal volume while also being
responsible for raising intra-abdominal pressure for pos-
tural stabilisation of the torso, parturition and micturi-
tion. Such considerations must be appreciated by the
therapist: when the respiratory muscles are required for
both motor and ventilatory functions, their ability to assist
ventilation is reduced. This is of particular importance
when ventilatory support has recently been reduced and
motor activity is being encouraged during daytime hours,
i.e. during the weaning and rehabilitative phases of recov-
ery. Upper limb strengthening exercises may be a primary
aim at this stage so increasing ventilatory support over-
night may be appropriate (Table 7.1).
129
 Tidy’s physiotherapy

Table 7.1  Comparison of skeletal muscle fibre types

Characteristics Type I Type IIa Type IIb

Contractile
Contraction velocity Slow Fast Fast

Myosin adenosine triphosphatase Slow Fast Fast

Twitch duration Long Short Short

Calcium ion sequestration Slow Rapid Rapid

Metabolic
Capillaries Abundant Intermediate Sparse

Glycolitic capacity Low Intermediate High

Oxidative capacity High High Low

Glycogen content Low Intermediate High

Myoglobin content High Intermediate Low

Fibre diameter Small Intermediate Large

Motor unit size Small Intermediate Large

Recruitment order Early Intermediate Late

(Reproduced from Schauf et al. (1990), with permission.)

The respiratory muscles share the common features of
other skeletal muscles and consist of a mixture of fibre
types (Johnson et al. 1973). The proportions of fibre types
and the metabolic constituents (e.g. capillaries; glycolytic
and oxidative capacities; and time of recruitment in con-
traction) determine a muscle’s strength and endurance
properties (Schauf et al. 1990). Type I fibres are important
for endurance (slow twitch, high oxidative capacity are
recruited first and are most resistant to fatigue). Type IIa
fibres have a higher oxidative capacity, fast twitch and
produce an intermediate level of force, and so are relatively
resistant to fatigue, while Type IIb fibres have a low oxida-
tive capacity, fast twitch, produce the greatest force on
activation, are the last to be recruited for motor efforts and
are easily fatigued when used repeatedly. Greater knowl-
edge of muscle physiology is required if the aim is to train
the respiratory muscles, rather than rest them (via ventila-
tory support). Muscle training may be an appropriate
physiotherapy intervention to facilitate the weaning
episode of the prolonged ventilatory supported individ-
ual, where muscle wasting and disuse atrophy are evident,
though more research is required in this area.
Respiratory mechanics and airflow
Contraction of the respiratory muscles affects the overall
motion of the chest wall, for example in the upright
position, on inspiration, the diaphragm moves down-
wards on contraction while the abdomen moves out.
Synchronicity is achieved when the rib cage and the
abdomen move together, increasing in diameter during
inspiration and decreasing in diameter during expiration.
In the supine position, most movements are abdominal
with little movement of the rib cage. Body position in
both respiratory mechanics and ventilation to perfusion
matching is of great importance, as respiratory muscle
dysfunction alone, for example fatigue or weakness,
can lead to dyspnoea, hypoventilation, hypercapnoea,
reduced oxygenation of body tissues, respiratory failure,
metabolic acidosis and, ultimately, death.
Normal resting ventilation is a tri-cyclical activity con-
sisting of the inward flow of air (inspiration), the outward
flow (exhalation) and the rest phase, which constitutes the
zero-flow status. During the inspiratory and expiratory
cycles, a volume of air moves in and out of the lungs. These
changes occur as a result of pressure gradients between the
airway opening (or mouth) and the alveoli. Prior to the
beginning of inspiration, the pressures at the airway
opening and in the alveoli are equivalent. As there is no
pressure gradient, there is no air movement – this is
known as the resting period of the respiratory cycle, where
air neither enters nor leaves the lungs (see Figure 7.1).
As inspiration begins the respiratory muscles contract,
causing an upward and outward movement of the chest

130
 Adult spontaneous and conventional mechanical ventilation Chapter 7

wall (the bucket and pump handle effects) and the dia-
phragm descends (see Figure 7.2). This is known as the
active phase of the breathing cycle and demands effort
(termed the work of breathing). The changes in thoracic
dimensions create a drop in the alveolar pressure; the pres-
sure gradient between the airway opening and the alveoli
results in an inward movement of air. The volume change
that occurs is called the tidal volume and is, on average,
500 mL. (Joint guidelines by the British Thoracic Society
and Association of Respiratory Technicians and Physiolo-
gists are available for a detailed underpinning of spiromet-
ric values and tests. Also downloadable from the internet
are the American and European thoracic society recom-
mendations for spirometry).
The pressure change that is generated on inspiration
must be sufficient to overcome such forces. The effort
required and the resulting volume change is termed the
‘work of breathing’. Normally, the work of breathing
is minimal (healthy lungs). A pressure gradient of
2–5 cmH2O is typically needed to move the average
tidal volume.
The elastic forces are encountered as a result of both the
lungs and chest wall being ‘elastic’ structures, i.e. they
resist changes in shape. When they have been inflated or

The opposing forces to ventilation

The work of breathing derives from the two resistive forces
of the lungs and chest wall, i.e. the elastic (see Figure 7.3) Recoil of lung
and frictional forces. Forces within the respiratory system PL = Palv–Ppl
that oppose inflation of the lung and therefore ventilation
can be grouped into two categories:
• the elastic opposition to expansion of the lungs;
• the frictional opposition or resistance to air
movement.

0
Equal pressures at the Recoil of respiratory system Recoil of chest wall
mouth and alveolus PRS = Palv–Pbs Pw = Ppl–Pbs
Figure 7.3  The elastic forces of the lung and chest wall.
0 0 Palv = alveolar pressure (pressure within the alveoli); Pbs =
pressure at the body surface; Pl = transpulmonary pressure
No airflow (pressure difference across the lung); Ppl = pleural pressure;
PRS = pressure with the respiratory system; Pw = pleural
pressure minus pressure at the body surface (= elastic recoil
pressure of the chest wall). (Courtesy of the Johns Hopkins
Figure 7.1  Spontaneous breathing: rest phase. University website.)

0 Muscles contract

– – Thoracic diameter
increases
– –
–2 –2
– Alveolar pressure
– decreases
–
– – Air flows in

A Inhalation pressure B

Figure 7.2  Spontaneous breathing: inspiratory phase. (Courtesy of the Johns Hopkins University website.)

131
 Tidy’s physiotherapy
Ø Ø
Ø Ø
Ø Ø
Ø
Ø 1
Expiratory pressure
Figure 7.4  Expiratory pressures. (Courtesy of the Johns Hopkins
University website.)
deflated, they tend to return to the same resting/starting
position of equilibrium once the driving force has been
removed. The lungs naturally want to collapse and the
chest wall naturally to expand. Thus, each exerts a pull on
the other. In the absence of other forces (e.g. muscles) a
position is reached in which the opposing forces are
balanced.
Owing to these opposing forces (of lung and chest wall),
the intrathoracic pressure is negative (sub-atmospheric).
To inflate the lungs an extra force must be applied (by the
muscles) and intrathoracic pressure falls lower.
Expiration is mostly passive as a result of the elastic
forces returning the lungs and chest wall to a balanced
position (Figure 7.4). It can, however, be active, for ex­­
ample forced breathing and coughing, where the expira-
tory muscles assist the elastic forces (resulting in a more
rapid expiratory rate of flow and faster lung deflation).
The inspiratory muscles perform mechanical work
through upsetting the balance of the elastic forces. Hence,
the harder and faster the respiratory effort is, the more
‘elastic’ work is required. A certain amount of pressure is
required to stretch the lungs to a certain volume. The
normal value for elastance is around 10 cmH2O/L.
However, in disease states, the lungs become stiffer and
the same pressure change may result in a smaller volume
change, i.e. the elastance of the lung is higher. Pneumonia,
acute respiratory distress syndrome (ARDS) and pulmo-
nary oedema are common lung conditions affecting
elastance. Others include fibrotic lung disease, pleural
effusion, kyphoscoliosis and obesity.
Compliance
Compliance (demonstrated by the pressure volume curve)
is a measure of the distensibility of the lungs or ease with
which the lungs inflate (i.e. the reciprocal of elastance). It
is measured as the change of volume in the lungs in
response to a change in pressure. Normal lung and chest
wall compliance is ~1L per kPa (100 mL per cmH2O). It
can be seen in Figure 7.5 that lung compliance is lowered
132
5 Emphysema
Normal
4
Volume (L)
3
Fibrosis
2
0
10 20 30 40
Distending pressure (cmH2O)
Figure 7.5  Lung compliance curves.
at high and low lung volumes. Hence, it is favourable for
the patient to sit on the steep slope portion of the curve
(it is easier to inflate a partially opened lung than a col-
lapsed lung).
The frictional forces
The second group of opposing forces encountered in ven-
tilation is the frictional forces. Impedance to air move-
ment through the airways is called airways resistance. A
small, but measurable, amount of work must be done to
maintain the flow. Frictional forces are therefore depend-
ent upon the speed with which air moves through the
airway. Resistance is defined as the ratio of the pressure
change responsible for air movement and the rate of flow.
A normal value for resistance is around 2.5 cmH2O/L/sec.
Factors affecting airways resistance include the size of
the airway, its shape and calibre (Figure 7.5). Different
diseases affect such properties, thus altering airway resist-
ance, for example chronic obstructive pulmonary disease
(COPD) is the most frequently encountered lung disease
that increases airways resistance.
With the presence of lung disease, the opposing forces
of ventilation are increased. To sufficiently ventilate the
lungs, larger patient efforts may be necessary to generate
the pressure change needed to overcome the increased
elastance or resistance (see Figure 7.6). Sustaining large
inspiratory efforts may lead to excessive workloads and
eventually respiratory fatigue and failure.
When the work of breathing is excessive because of an
increase in the elastic or resistive forces present, respiratory
muscle weakness from fatigue may develop. The strength
of the muscles will be inadequate to support normal levels
of ventilation and muscle pump effectiveness is dimin-
ished resulting in inadequate ventilation and an increase
in the arterial carbon dioxide level (PaCO2) causing respi-
ratory acidosis. Hypoventilation or respiratory muscle
fatigue may also lead to severe hypoxia. Under these
 Adult spontaneous and conventional mechanical ventilation
Normal
Flow/volume
Diseases
Effort
Figure 7.6  The relationship between patient effort and flow/
volume.
conditions, ventilatory support to unload the respiratory
muscles and improve ventilation is indicated.
Body positioning, pharmacological management and
oxygen therapy are of prime importance to reduce the
opposing forces of respiration and maximise ventilation
prior to, and during, the instigation of mechanical support.
RESPIRATORY FAILURE
Respiratory failure occurs when there is an imbalance of
ventilatory requirements to neurocardiorespiratory capac-
ity. It is a common medical condition that occurs when
the lungs fail to oxygenate arterial blood adequately (type
I respiratory or lung failure) and/or the muscle pump fails
to prevent undue CO2 retention (type II ventilatory or
pump failure). While no absolute diagnostic values for
arterial oxygen (PaO2) and PaCO2 have been defined,
values generally quoted are a PaO2 of less than 8.0 kPa
and a PaCO2 of greater than 6.0 kPa (Roussos and
Koutsoukou 2003).
Arterial blood gas tensions must be measured to make
the diagnosis of respiratory failure, as many of the accom-
panying signs and symptoms, for example breathlessness,
dyspnoea, cyanosis, agitation and the use of accessory
muscles, are not diagnostic of the condition. Oximeters
that estimate arterial oxygen saturation (SaO2), either
from the finger or earlobe, are useful tools for indicating
hypoxaemia (SaO2 <90%), assessing severity and monitor-
ing the patient’s condition. Accordingly, all respiratory
compromised patients should have oximetry checked. It is
important to note, however, that this may be falsely reas-
suring in the patient receiving supplemental oxygen, as
alveolar hypoventilation is not detected. Unconscious
patients should, therefore, have arterial blood gas analysis
at initial assessment to exclude respiratory failure either as
a cause or consequence of neurological depression.
Chapter 7
Table 7.2  The typical clinical features of type I
respiratory failure
Hypoxia
Hypocarbia
Tachypnoea
Small tidal volumes
Acute hypoxaemic (type I)
respiratory failure
This is caused by intrinsic lung disease that interferes with
oxygen transfer in the lung. Hypoxaemia results from
increased right-to-left shunts (e.g. pneumonia, alveolar
collapse, oedema and consolidation) or, more signifi-
cantly, ventilation perfusion (V/Q) mismatch, for example
pulmonary parenchymal disease, or a combination of the
two. Where functional residual capacity (FRC) is reduced,
airway closure is present throughout the respiratory cycle
as tidal exchange occurs below closing volume. This results
in an increased number of under-ventilated lung units
(placing the patient lower down on the compliance curve).
The increased dead space (air in the airways which does
not directly contribute to gas exchange) results initially
in an increase in total ventilation to maintain a normal
PaCO2. This is because in areas of V/Q inequality, the
raised arterial PCO2 resulting from decreased CO2 excre-
tion in the under-ventilated alveoli stimulates the res­
piratory centre. Relative hyperventilation may ensue in
response to severe hypoxaemia with a resultant drop
in PaCO2 to below normal range. (The degree of hypoxae-
mia is restricted by constriction of the blood vessels
supplying under-ventilated alveoli, i.e. hypoxic pulmonary
vasoconstriction.)
The mechanical disadvantage of a reduced FRC results
from the consequential reduction of lung compliance and
increased resistance, resulting in a greater work of breath-
ing with a higher metabolic cost. The resultant clinical
picture is that of rapid shallow breathing, which, in turn,
further increases both oxygen consumption and carbon
dioxide volume for excretion (Table 7.2).
Ventilatory (type II) respiratory
failure
This is caused by failure of the respiratory pump (consist-
ing of the respiratory muscles, chest wall, higher centres
and nerves) where the amount of CO2 excreted is less
than that produced by metabolism. With respiratory
pump failure, even with normal lung pathology, the arte-
rial PaCO2 is raised, with an inevitable fall in alveolar
oxygen tension and hypoxaemia (alveolar hypoventila-
tion). Hypoventilation results from a reduced respiratory
effort, an inability to overcome resistive ventilatory forces
133
 Tidy’s physiotherapy
Neuromuscular competence
Impaired drive Muscle weakness
• Drug overdose • Electrolyte
• Brain-stem lesion derangement
• Sleep deprivation • Malnutrition
• Starvation/malnutrition • Myopathy
• Metabolic alkalosis • Hyperinflation
• Sleep disorders • Atrophy
• Sepsis
Figure 7.7  Neuromuscular competence.
Table 7.3  The typical clinical features of absolute
type II ventilatory failure
Hypercarbia
Hypoxia
Reduced respiratory rate and or tidal volumes
Mixed respiratory failure
or an inability to compensate for extra deadspace and/or
CO2 production. The respiratory muscle pump is as vital
as the heart, failing in the same way and for the same
reasons, but a large respiratory reserve is present and
function may be markedly impaired without ventilatory
failure accompaniment (Table 7.3).
It is worth noting at this point that a mixed picture of
the two types of respiratory failure is frequently seen.
While acute hypoxaemic failure may initially be present,
some cases result in exhaustion. The patient is unable to
compensate for the increased dead space, resulting in a
raised PaCO2 tension and mixed respiratory failure. Where
individuals are unable to cough effectively or sigh, the risk
of alveolar collapse, secretion retention and secondary
infection is further increased. Others may be at risk of
aspiration, for example unconscious or bulbar palsy,
causing further damage to the lungs and further worsening
ventilatory function.
Pathways to respiratory failure
The causes of respiratory failure are too numerous to detail
but can be divided into two main categories:
• a reduction in neuromuscular competence resulting
in the inability to generate adequate respiratory
muscle force, for example reduced central drive,
spinal injury, trauma, muscle disease (Figure 7.7);
• an increase in respiratory workload caused by raised
ventilatory impedance, for example obstructive and
restrictive lung defects.
134
Impaired/transmission
• Phrenic nerve injury
• Spinal cord lesion
• Neuromuscular
blockers
• Myasthenia gravis
• Guillain−Barré/polio
• Critical illness
Table 7.4  Causes of acute alveolar hypoventilation
1. Chest wall, pleural and airway diseases
• Loading (obesity)
• Deformity (pectus/kyposcoliosis)
• Upper airway obstruction (trachea/larynx)
• Generalised disease (asthma/bronchitis/emphysema/
cystic fibrosis)
2. Neuromuscular diseases and transmission
• Spinal cord (injury/tumour)
• Anterior horn cell (polio)
• Peripheral neuropathy (Guillain-Barré)
• Neuromuscular junction (Myasthenia gravis)
• Muscle cell (dystrophies/myopathies)
• Amyotrophic lateral sclerosis
3. Reduced central drive
• Drugs (sedatives, pain killers)
• Central nervous system disease (stroke, trauma)
4. Other
• Sepsis
• Shock
(Reproduced from Roussos and Koutsoukou (2003), with
permission.)
Respiratory muscle dysfunction occurs as a result of
various factors. This can be demonstrated by considering
COPD, where respiratory muscle function is profoundly
affected as a result of the increased work of breathing
and the increased ventilatory load. The increased work of
breathing arises from the pathological changes resulting
in raised airway resistance and hyperinflation. At rest, the
minute volume of these patients is higher than that of
healthy subjects. As a result, the actual cost of breathing
in terms of oxygen consumption is markedly increased
and the accessory muscles of respiration are recruited.
Hyperinflation also has adverse effects upon the respira-
tory muscles. The increased lung volumes in COPD are
thought to be compensated for by the lowering of the
 Adult spontaneous and conventional mechanical ventilation
diaphragm or expansion of the rib cage. These changes
result in the muscles functioning at a disadvantaged posi-
tion on the length-tension curve, i.e. the diaphragm is at
its optimal length for providing the maximum contractile
force when it is in its resting domed position.
As lung volume increases, the inspiratory muscles
shorten and their ability to generate a negative force on
inspiration is reduced. Hence, the inspiratory effort
required to obtain the same tidal volume is greater. A
completely flattened diaphragm is incapable of generating
any useful pressure and on contraction causes in-drawing
of the lower rib cage (Hoover’s sign), effectively function-
ing as an expiratory muscle (see intrinsic positive end-
expiratory pressure (PEEPi) below).
Respiratory muscle fatigue is an important precursor to
respiratory failure. Factors affecting the endurance of the
respiratory muscles include energy stores/nutrition, blood
substrate concentration, arterial oxygen content, efficiency,
mean inspiratory flow, minute ventilation, inspiratory
duty cycle and maximum inspiratory pressure.
When fatigue of the respiratory muscles occurs, rest, not
exercise, is indicated. However, a delicate balance between
the two must be achieved as there is some evidence that
if total rest is applied (through the application of full
mechanical ventilation) disuse atrophy may occur causing
weaning problems.
Increases in both elastic and resistive loads, as present
with lung disease, will therefore increase the work of
breathing and can lead to respiratory muscle fatigue and
weakness, as described previously. When fatigue ensues,
hypoventilation will result and weakened muscles will be
unable to overcome the opposing forces of respiration to
maintain adequate ventilation. Unless ventilatory support
is provided to ‘unload’ the system, respiratory failure
results.
The hypoxic drive concept
One of the causes of CO2 retention in respiratory failure is
the use of inappropriate levels of supplemental oxygen.
This relates to only a small, but important, group of
patients in whom the main ventilatory drive is hypoxae-
mia. Some patients with COPD develop severe hypoxae-
mia with some CO2 retention. Owing to the degenerative
pathological changes within the lungs, this is maintained
over long periods of time and, while not referred to as res-
piratory failure, an increased work of breathing is usually
encountered. Arterial pH is usually at the lower end of the
normal range as renal compensation for the raised arterial
CO2 occurs with time and bicarbonate is retained (com-
pensated respiratory acidosis). The cerebrospinal fluid
also has a normal pH because of the raised bicarbonate
levels and the main ventilatory drive now arises from the
hypoxaemia (despite the raised arterial PCO2).
The subsequent administration of high inspired oxygen
fractions in such cases may pose a potentially lethal
Chapter 7
clinical scenario as the hypoxic drive will be abolished
while the detrimental effects of the underlying lung condi-
tion and increased work of breathing continue. The result
is gross respiratory depression with the arterial PaCO2
climbing and arterial blood pH falling to extreme levels if
left unnoticed or is misinterpreted in the clinical setting.
MECHANICAL VENTILATION
The goals of ventilatory support are clearly defined. They
are to:
• improve alveolar ventilation;
• decrease the work of breathing;
• improve gas exchange.
Mechanical ventilatory support alone will not change
the opposing forces of ventilation. The objective of
mechanical ventilatory support is to reduce the impact of
those forces until the abnormality resolves.
A potted history
Ventilation has a long history of development. There is
some descriptive evidence of the artificial ventilation of
animals via a reed or cane tube as early as the 1500s
(Vesalius 1543). Perhaps the first patient reports date back
to the 1700s when physicians used ironmongers’ bellows
to force air into their patients’ lungs (Royal Humane
Society 1774). Ventilation truly began in the 1830s, with
negative pressure devices being the main ventilatory sup-
ports (Woollam 1976). The switch to positive pressure
ventilation (PPV) did not occur until around 1952 when
the ability to intubate and tracheostomise patients was
established during the polio outbreak in the 1950s. Inva-
sive ventilatory support using positive airway pressure
soon became the main stem treatment, initially using
volume-cycled ventilators (Figure 7.8).
Ventilatory support is usually given with the assistance
of a mechanical device or ventilator. This can be done in
one of two ways.
1. Invasively: the upper airway is bypassed using an
endotracheal tube (ETT) or tracheostomy.
2. Non-invasively: the patient is given ventilatory
support via the upper airway (not featured in this
chapter).
In both methods air is mechanically driven through the
patient’s lungs to assist alveolar ventilation.
Invasive/conventional ventilation
Conventional (invasive) ventilation and the methods of
cycling used have undergone different stages of develop-
ment. Initially, volume ventilation was the norm, but
‘ridged lung’ problems were encountered, along with
135
 Tidy’s physiotherapy
patient and machine asynchrony (hence the term ‘the
patient is fighting the ventilator’). There are two primary
methods of cycling used: volume and pressure controls.
Volume controlled ventilation
Volume controlled ventilation requires that a predeter-
mined tidal volume be delivered to the lungs. A positive
pressure is created at the airway, which continues to
increase until the specified volume is achieved. Other con-
trols to be set on a volume ventilator include the number
of breaths per minute the patient will receive and the rate
of flow at which the volume is delivered to the lungs. A
machine delivering a fixed rate of flow for a specified time
will guarantee a specified tidal volume but is actually time-
cycled. Where flow measuring devices are sited at the Y
connector, a true volume-cycled machine will compensate
for leaks upstream of the connector where time-cycled will
not (Sykes and Young 1999).
Volume ventilation meets the goals of ventilatory
support in that it guarantees a specified amount of ventila-
tion. This is appropriate today in the operating theatre
setting. The disadvantages of volume controlled ventila-
tion result from ‘setting’ (and, hence, enforcing) the vari-
ables of normal breathing – tidal volume (Vt), respiratory
rate (RR) and the I : E ratio (i.e. the amount of time spent
in inspiration versus expiration). The usual I : E ratio is 1 : 2
as inspiration is active, while expiration is largely passive
and thus needs longer for air to empty from the alveolar
units. If expiration is too short, air trapping will occur and
PEEPi results (thus increasing the risk of lung trauma
owing to excessive pressure).
With such controlled cycling, the patient must adapt to
the ventilator rather than the ventilator adapting to the
patient. This may cause dys-synchronisation between
machine and patient, sometimes further increasing a
patient’s work of breathing, so indicating the need for
sedation ± drug-induced paralysis until the disease process
136
Figure 7.8  Porta lung ventilator. (Courtesy of
www.nemc.org/RespCare/portalng.htm.)
is resolved. In some instances, the patient may stop inter-
acting with the ventilator. With disuse over time, the res-
piratory muscles atrophy and problems with weaning
through muscle weakness and an inability to endure the
requirements of normal resting breathing in an already
compromised patient may be encountered. Ventilating
pressures may be high leading to lung damage, and over-
ventilation may occur if ventilatory requirements are
overestimated.
Pressure controlled ventilation
Pressure controlled ventilation is frequently used to guar-
antee a maximum inflation pressure and reduce the risks
of barotrauma (see complications). This mode can be used
only when a pressure generator delivers increasing pres-
sure throughout inspiration or with a flow generator.
Minute ventilation (i.e. RR × Vt) cannot be guaranteed as
with volume cycled ventilation (Sykes and Young 1999),
as a pressure limited breath is delivered at a set rate. The
volume generated is determined by the preset pressure but
is also under the influence of the time spent in inspiration,
the compliance of the lung and chest wall and airways
resistance. Hence, hypoventilation and hypoxaemia may
result with inadequate settings. However, the decelerating
flow (as airway pressure rises and alveolar volume
increases, the rate of flow slows) and maintenance of
airway pressure over time, are more likely to inflate the
more difficult non-compliant lung units.
Ventilation modes
Both volume and pressure control are cycles, rather than
modes, of ventilation. As such, these controlled methods
are significantly different to the spontaneous breathing
cycle where the inspiratory flow and rate are of the indi-
vidual’s own choosing. In the 1970s and 1980s assisted
modes that allowed spontaneous respiratory efforts were
 Adult spontaneous and conventional mechanical ventilation
introduced, and assist control and synchronised intermit-
tent mandatory ventilation modes were developed for
both volume and pressure controlled mechanisms. In
turn, this led to the more sophisticated triggering and
interactivity microprocessor developments of today’s ven-
tilators, resulting in full patient interaction. The ventilator
was now becoming an interactive weaning device. However,
concern regarding ventilator-induced damage became
prevalent throughout the 1990s (Tobin et al. 2001) and
protective strategies of alveolar recruitment using PEEP
and lower tidal volumes to maintain a higher mean airway
pressure and limiting plateau pressure emerged (ARDS
Network 2000). Such protection strategies were detailed
by MacIntyre in 2005.
Numerous modes (including dual modes enabling the
combination of pressure limited with volume guaranteed
ventilation) have since been developed with more sophis-
ticated valves and control features, for example rise time
(the speed with which the preset pressure/volume is
reached), tube compensation as an automatic feature and
active exhalation valves to name but a few. The aim of
these is to enable improved patient comfort, synchrony
and interaction, while allowing greater reductions in the
risks of associated ventilatory lung trauma.
Pressure supported ventilation
In the last 10 years, pressure supported ventilation, as
opposed to pressure controlled ventilation, has become
the mode of choice as it offers better synchrony for the
patient and the delivered flow can be more easily changed
to suit differing lung and chest wall compliance. In this
mode, a preset pressure acts as the limit while the patient
is assisted but remains in control of all respiratory varia-
bles. Pressure support serves to reduce the work of breath-
ing in inspiration and results in a larger tidal volume than
a spontaneous breath alone by pushing the patient up the
compliance curve. Where FRC is reduced, PEEP/continuous
positive airways pressure (CPAP) can also be applied,
which serves to restore the resting FRC back to the normal
volume.
Advanced pressure modes
Airway pressure release ventilation (APRV), bilevel ventila-
tion and proportional assisted ventilation (PAV) are
advanced pressure modes. APRV mode is usually reserved
for severe ARDS (where hypoxaemia is a major problem
despite a high inspired oxygen fraction) and allows venti-
lator cycling between two different set CPAP levels (high
and low) with the higher level providing the baseline pres-
sure. The pressure is then intermittently ‘released’ to the
lower CPAP level to enable CO2 elimination. Bilevel ven-
tilation is the same as APRV but allows spontaneous
breathing at either CPAP level, with the spontaneous
breaths being supported by either tube compensation or
Chapter 7
pressure support. The mode is well-tolerated and sedation
is not usually necessary. This single mode can be used to
provide full support through to facilitating weaning.
PAV is a form of ventilation that is fundamentally dif-
ferent from volume and pressure ventilation. In PAV
mode, the ventilator generates a pressure change to cause
airflow and move volume into the patient’s lungs. Unlike
conventional ventilation the pressure is generated in pro-
portion to the patient’s own inspiratory efforts. PAV tracks
and responds to changes in the patient’s breathing pattern/
efforts and augments ventilation on a breath by breath
basis. This means the patient has total control of breathing
– their natural effort is simply amplified. The pressure
delivered corresponds to changes in elastance, resistance
and flow demand.
The development and efficacy of newer strategies con-
cerning neurologically adjusted ventilatory assist modes
are under consideration in the UK. This technology is
based on a concept that couples the diaphragm and the
mechanical ventilator by capture of the electrical signal
from active diaphragmatic work and feedback to the ven-
tilator for control of the assist portion required, as dictated
by the patient’s own physiological (neural) demand.
The complications of mechanical
ventilation
Significant pulmonary and non-pulmonary complications
may arise at any time as a direct consequence of intubation
and mechanical ventilation, some of which are life-
threatening. Intubation itself may cause upper airway
trauma, loss of teeth, lacerations or trauma (including
perforations) to the pharynx, vocal cords or trachea, and
inadvertent intubation of the oesophagus or right main
bronchus. Longer-term intubation may result in sinusitis,
necrosis/stenosis of the trachea and glottic oedema.
Retained pulmonary secretions are common in the venti-
lated patient as the cough reflex is impaired, mucociliary
transport is reduced and mucus production increased
(Plevak and Ward 1997).
Pulmonary complications
Pulmonary complications that commonly occur are atel-
ectasis, infection and alveolar over-distension (causing the
life-threatening problems of hypotension, and barotrauma
or volutrauma (also referred to as atelectrauma)).
Atelectasis
Atelectasis is a common problem in the ventilated indi-
vidual. Causative factors include aspiration, hypoventila-
tion, mucus plugging and secretion retention. Intubation
of the right main bronchus may cause over distension of
the right lung (which may be reflected by high inflation
pressures), while the left lung becomes atelectatic. A loss
137
 Tidy’s physiotherapy

of lung volume, as found with atelectasis and lobar/total Applied PEEP PEEPi
lung collapse, will be evident on chest radiograph as a shift
toward the affected side with increased opacity and dia- +5 cmH2O 0 cmH2O
phragmatic elevation or tenting.
Aspiration (a particular risk at the time of intubation)
is most likely to affect the right lung in the supine position
owing to the anatomy of the right main bronchus as it
branches from the trachea (more vertically than the left).
Correct positioning of the ETT and its patency should be +5 +5
checked along with the auscultation of breath sounds on
a regular basis. The correctly placed tube should be appro- A B
priately secured and the weight of the circuit supported to
Figure 7.9  Diagram to demonstrate PEEP and PEEPi.
prevent loss of alignment (and subsequent misplacement/
(a) Applied PEEP. (b) PEEPi.
accidental extubation, or erosion and trauma) within the
trachea.

Ventilator-induced lung injury curve (a mechanically advantageous position for ventila-

This consists of barotrauma and volutrauma caused by
over-distension of the alveolar units. Barotrauma is the
rupture of alveoli resulting in the tracking of air to the
pleura (pneumothorax) or mediastinum (pneumomedi-
astinum). Predisposing risk factors include large tidal
volumes and high peak (pressure in the main airways) and
plateau (pressure in the small airways) pressures, although
predisposing lung pathology may be a better indication of
risk. There is usually a gradient between the peak and
plateau pressures. However, ventilating pressures below
45 mmHg and 35 mmHg respectively are recommended.
The I : E ratio is an important consideration in COPD suf-
ferers requiring ventilatory support owing to the increased
risk of PEEPi development in the presence of increased
airways resistance. Manipulation of parameters affecting
the I : E ratio may, therefore, be required, such as increasing
the inspiratory flow rate or reducing the ventilatory rate.
Volutrauma (the over-distension of alveoli) has led to the
development of lung protection strategies more prevalent
today of lower tidal volumes (6–8 mL/kg). When deliver-
ing PPV, air takes the path of least resistance. Thus, normal
or relatively normal alveoli are ventilated more easily than
collapsed or consolidated lung units and the potential for
over-distension (resulting in an increased risk of activating
an inflammatory reaction of the normal areas) is estab-
lished. MacIntyre (2005) emphasises that the forces asso-
ciated with the repeated opening and closing of alveoli
through tidal gas exchanges is linked to worsening inflam-
matory cascades, so those with acute lung injury or ARDS
are recommended protective strategies of PEEP with low
volumes and a higher plateau airway pressure to avoid
such forces, with a speedier wean from ventilation through
adherence to respiratory therapy-led weaning protocols
(Ely et al. 1996).
In the mechanically-ventilated patient, a positive pres-
sure (CPAP/PEEP) may be applied at the end of expiration
(Figure 7.9) in order to recruit the dependent alveoli. In
addition to moving the patient onto the more favourable
steep portion of the lung compliance (pressure/volume)
tion), this splinting effect on the airway also enables a
longer period of time for oxygen to diffuse across the
alveolar-capillary membrane, thus improving the oxygena-
tion status of the patient.
PEEPi
PEEPi (Figure 7.9) may develop automatically within the
airway, for example because of chronic lung diseases,
inappropriate settings of applied ventilatory support and
clinical dynamic hyperinflation states, such as status asth-
maticus. PEEPi occurs when the expiration phase is inad-
equate in duration for the lung to fully empty prior to the
next inspiratory breath (regardless of type). As such, a
proportion of each subsequent tidal volume may be
retained and if undetected, result ultimately in baro-
trauma, volutrauma, hypotension, patient-machine dys-
synchrony and even death.
Oxygen toxicity
Oxygen toxicity (owing to the production of oxygen free
radicals) is associated with higher maintenance levels of
inspired oxygen fractions and duration of use. It results in
complications such as absorption atelectasis, hypercarbia,
tracheobronchitis and diffuse alveolar damage. The lowest
level of fractional inspired oxygen (FiO2) required while
maintaining adequate oxygenation is recommended, with
downward titrations encouraged as soon as possible. The
exact level thought to be responsible is as yet unknown,
although damage has been reported with maintenance
levels of 50%. Again, the application of PEEP may help
with the oxygenation status of the individual and the low-
ering of inspired oxygen fractions if the pressure is haemo-
dynamically tolerated.
Ventilator associated pneumonia
Ventilator associated pneumonia (VAP), a life-threatening
complication (with reported mortality rates of up to 50%)
(Rea-Neto et al. 2008), poses a significant risk and is
reported to occur in 13–35% of mechanically-ventilated

138
 Adult spontaneous and conventional mechanical ventilation
patients. Early onset pneumonia (within 48–72 hours of
intubation) may be a result of aspiration at the time of
intubation. Most are caused by antibiotic-sensitive organ-
isms and flora of the upper airway, such as Staphylococcus
aureus, Haemophilus influenzae and Streptococcus pneumo-
niae. Infections after 72 hours are thought to be caused
by antibiotic-resistant pathogens, for examople Pseuda-
monas aeruginosa (prevalent in percutaneous tracheos-
tomised patients, as shown by Rello et al. 2003) and
acinetobacter species. Often precursors to VAP are bacte-
rial colonisation of the aerodigestive tract and aspiration
of contaminated secretions into the lower airways (Kollef
2002; Byrd et al. 2006). VAP should be suspected if
there is evidence of pyrexia, radiological changes and
purulent pulmonary secretions. Cultures obtained from
pulmonary aspirate may not reliably differentiate between
pneumonia and tracheal bacterial colonisation. Secretions
obtained via fibreoptic bronchoscopy may be useful, but
this technique poses the risk of PEEPi development and
poor tidal volumes in the ventilated patient (Lawson et al.
2000). (Preparation and ventilatory alterations may be
required prior to this procedure, e.g. the ETT internal
diameter should be at least 2 mm greater than the external
diameter of the bronchoscope.) Of note in the longer-term
ventilated patient, Baram et al. (2005) found that stable
patients with no clinical signs of pneumonia carry a higher
burden of bacteria that is usually greater than the com-
monly accepted threshold diagnostic of VAP. Georges
et al. (2000) also recommend that those requiring trache-
otomy with evidence of bronchial colonisation and
pyrexia should have the procedure delayed to prevent the
risk of acquiring early PAV. Predisposing risk factors for
the acquisition of VAP include surgical procedures (tho-
racic and upper abdominal), nasogastric tube use, supine
position, reintubation, previous antibiotics, chronic lung
disease, and use of histamine 2 receptor antagonists and
antacids (Celis et al. 1988; Torres et al. 1990). There is
recognition that bacterial colonisation of the upper airway
may cause contamination of the lower airway despite
the use of a tracheal cuff (Feldman et al. 1999) and
that there is usually bacterial colonisation in tracheo­
stomised patients on longer-term ventilatory support
(Lusardi et al. 2003).
The literature favours the use of initial broad-spectrum
antibiotics until the sensitivities of the causative agents are
identified. These will usually be tailored to local organ-
isms and antimicrobial resistance. The aspiration of sub-
glottic secretions is also important in reducing the risk of
upper tract colonisation and vigilant cuff management
should be adopted to clear secretions pooling there (Girou
et al. 2004). Gastric distension should be avoided and a
semi-recumbent position used (Girou et al. 2004) to
reduce the risk of aspiration (Orozco-Levi et al. 1995).
Avoidance of unnecessary antibiotic administration and
rotation of such medication may also be useful in preven-
tion tactics.
Chapter 7
Non-pulmonary complications
These include venous thromboembolism (with predispos-
ing risk factors of trauma, immobilisation, obesity, cardiac
failure and underlying malignancy) requiring prophylaxis,
for example anticoagulation and elastic stockings; various
gastrointestinal problems (Mutlu et al, 2001) (predispos-
ing factors include burns, coagulopathy and head injury)
owing to stress ulceration requiring gastric protection
strategies; pressure sores which may lead to sepsis or
osteomyelitis; neuromuscular weakness and atrophy; and
other organ failure.
The cardiovascular system is also inevitably affected in
some way with the use of mechanical ventilation. The
application of PPV may cause a reduction in preload,
stroke volume and cardiac output, which may then reduce
renal perfusion and, ultimately, renal function with fluid
accumulation. Maintenance of such positive thoracic
pressure can also cause a reduction in the return of blood
from the head resulting in a raised intracranial pressure
and delirium and agitation, making the already complex
multi-factorial management even more difficult.
THE ROLE OF THE RESPIRATORY
PHYSIOTHERAPIST
This role in intensive care is considered by many to be
an integral part of the overall management of the acutely
ill patient, although evidence is scant and varied, with
further controlled research being required in many areas.
The purpose and effectiveness of this area of physiotherapy
has been questioned by Templeton and Palazzo (2007),
but the lack of detail over the clinical decisions made and
the physiotherapy management during this randomised
controlled trial has affected the transferability of the
results. The trial did question the routine respiratory physi-
otherapy management of the ventilated patient, although
it was controversial because of the quality of the trial, but
the importance of emergency on-call care was recognised
and not denied to patients. This trial may question the
approach to physiotherapy respiratory care and therapists
should be seen to treat only when needed from the thor-
ough respiratory assessment rather than routine care.
In future years, the challenge for physiotherapists on
intensive care units will be to combine the vital respiratory
care needed to the rehabilitation needs of the patient
within critical care. Recent guidance from the National
Institute of Health and Clinical Excellence (NICE) has
highlighted this requirement. For a physiotherapist on an
intensive care unit, various techniques will be used which
will range from being a generic skill (i.e. exercises and
mobilisation) to a specialised respiratory skill (i.e. manual
hyperinflation). The specialist treatment strategies to the
critical care patient will be discussed in detail in this
chapter.
139
 Tidy’s physiotherapy
Pulmonary interventions
Interventions should be based upon assessment findings
and must include at least an ability to problem-solve
some basic issues with the ventilatory equipment, for
example factors affecting patients’ co-ordination of breath-
ing with the ventilator (Tobin et al. 2001), tube patency,
development of dynamic hyperinflation and intrinsic
PEEP, and discuss possible corrective measures with the
multi-disciplinary team; and an understanding of the
ventilator alarms and their significance. In order to do
this, a sound knowledge (the background to which has
been provided earlier in this chapter) of respiratory
mechanics is essential. If disconnection from the ventila-
tor for any reason is required, the physiotherapist must be
able to safely reinstate ventilatory support and check all
mechanical and physiological parameters. This should not
be assumed to be the responsibility of the accompanying
nurse, while competence with managing the respiratory
equipment and monitors should be gained prior to the
first emergency on-call duty.
Suction
Aspiration of pulmonary secretions via the artificial airway
is used for secretion clearance only when the patient is
unable to do this independently. It should never be used
‘routinely’ or prophylactically, as research demonstrates
undesired effects, for example tracheobronchial trauma
(Judson and Sahn 1994), hypoxaemia and destabilisation
of haemodynamics (Paratz 1992), although these are
limited with the use of pre-oxygenation, reassurance and
sedation, if required. To avoid unnecessary suction passes,
Guglielminotti et al. (2000) explored the bedside detec-
tion of retained secretions in the ventilated patient. They
recommend that a sawtooth pattern, as seen on the venti-
lator’s flow-volume loop, and/or respiratory sounds over
the trachea are good indicators (especially when there is a
combined presence) for the need for tracheal suction in
the ventilated patient, thus enabling performance of the
technique on an ‘as needed’ basis.
Many units now use closed suction catheters for a ven-
tilated patient, which takes away the need for a sterile
open procedure for suction. This is aimed at reducing the
risk of introducing new microorganisms to the airways
but, interestingly, Siempos et al. (2008) found no differ-
ences in the incidence of VAP when comparing the two
methods of suction. Despite these results, closed suction
may be preferred in units because of the ease of technique,
but the physiotherapist must be aware of both in cases of
emergency respiratory management.
Positioning
The use of specific body positioning in the intensive
therapy unit is aimed at optimising oxygen transport via
140
improving ventilation to perfusion (V/Q) matching, pro-
moting mucociliary clearance, improving aeration through
increased lung volumes and reducing the work of breath-
ing. It has been suggested that frequent re-positioning may
decrease the incidence of VAP (Clini and Ambrosino
2005) and this has resulted in the introduction of technol-
ogy to assist this. Continuous turning beds have been
studied and despite suggestions that they assist sputum
clearance (Davis et al. 2001), they were found not to affect
the patient’s length of stay in the intensive care unit or
days requiring ventilation (Goldhill et al. 2007).
When considering the positioning of the patient it must
be remembered that the semi-recumbent position at 45°
has been found to reduce the incidence of acquired pneu-
monia by preventing the risk of gastric reflux (Alexiou
et al. 2009). Also, upright positioning may be required for
weaning non-tetraplegic patients. Respiratory mechanics
are severely altered in the cervical and upper thoracic com-
plete spinal cord-damaged patient, and the supine posi-
tion should be adopted with no more than a 10° tilt.
Manual hyperinflation
Manual hyperinflation, which has still not been overtly
described owing to the many variations in technique used,
requires the patient to be disconnected from the ventilator
and attached to a manual circuit for the purpose of hyper-
ventilating the lungs in order to reinflate atelectatic lung
units (via collateral ventilatory channels). The potential to
both hypoventilate and over distend the lungs exists with
this modality and it is recommended that a simple pres-
sure gauge be used in circuit to minimise the risk of baro-
traumas (Figure 7.10). Perform a slow deep inspiration,
ensuring the pressure does not exceed 40–50 cmH2O
(Denehy 1999). It has previously been described as ‘…a
technique that uses a manual bag circuit to deliver a breath
of 1.5 times greater than that being delivered by the ven-
tilator, where the ventilator is recording a tidal volume
of up to 700 mls’ (Clapham et al. 1995, McCarren and
Chow 1998).
Evidence is inconsistent concerning the efficacy of this
technique owing to variables in studies. However, manual
hyperinflation is thought to be particularly useful in
Pressure gauge
Mapleson C
Figure 7.10  Diagram to show integration of a simple
pressure gauge in circuit.
 Adult spontaneous and conventional mechanical ventilation
reinflating atelectatic areas of lung and thus improving
pulmonary compliance (Clarke et al. 1999; Clini and
Ambrosino 2005) and oxygenation (Blattner et al. 2008),
providing a more efficient breathing pattern. It has been
found to reduce airway resistance (Choi and Jones 2005)
and facilitate sputum clearance (Savian et al. 2006). This
technique is traditionally seen as a key physiotherapeutic
technique, but should only be used if indicated by the
respiratory assessment.
Despite the advantages of this intervention, it must be
remembered that rises in intracranial pressure and signifi-
cant drops in blood pressure have been reported during
the technique, as airway pressure, the amount of PEEP
applied, flow rates and the FiO2 appear to be very variable
(Jones et al. 1992; Glass et al. 1993; Denehy 1999).
The technique used should ensure that the weight of the
tubing and valve is supported to avoid tracheal tube dis-
placement throughout the episode of intervention. It
should be performed ideally using a two-handed tech-
nique (especially if the hands are small), rotating the hand
at the reverse of the bag at a rate that matches the baseline
minute ventilation of the patient (Clapham et al. 1995).
The therapist should observe the chest and listen to feed-
back from the therapist performing the chest wall vibra-
tions to gauge the lung expansion obtained. The peak
inflation volume is held for a couple of seconds to obtain
a plateau, and then, if utilised, begin vibrations. The bag
is then released to allow rapid expiration. Manual vibra-
tions should be stopped midway through the expiration
phase to avoid collapsing the airways; however, full expira-
tion must occur prior to the next manual hyperinflation.
The techniques should be repeated 5–6 times or as clini-
cally indicated. Baseline parameters should be monitored
throughout the process and changes noted. Sudden altera-
tions to the cardiovascular stability of the patient should
result in discontinuation of the process, and effects docu-
mented alongside the recovery time and any adverse
effects. On completion of the intervention the patient
should be returned back to the pre-intervention ventila-
tion regime and observed for cardiorespiratory stability.
Outcomes of treatment and the future plan should be
clearly recorded. Note: synchronisation with the conscious
spontaneously breathing patient is essential to the success
of this procedure.
Because the intervention involves the disconnection of
the ventilator circuit and a potential loss of pressure and
de-recruitment of alveoli, some therapists have begun to
deliver hyperinflations via the ventilator. Savian et al.
(2006) compared ventilator hyperinflation with manual
hyperinflation and found increased lung compliance with
the ventilator technique. If hyperinflation via the ven­
tilator is to be attempted, agreement with the multi-
professional team must be agreed and parameters returned
to pre-technique levels following completion.
The clearance of oropharyngeal secretions should be
undertaken on a daily basis to remove stagnant pooled
Chapter 7
secretions from around the cuffed tube. It is most effec-
tively done with continuous manual pressurisation of the
lower airway to expel secretions as soon as the cuff is
deflated to avoid bacterial contamination of the lower
respiratory tract. Upon cuff reinflation, the cuff volumes
used should be in accordance with findings from occa-
sional cuff pressure checks to avoid tracheal pressure
damage, and the volume of air required to adequately and
safely seal the cuff, should be documented.
Manual techniques
Manual techniques are often used in conjunction with
manual hyperventilation, such as shaking and vibrations
to facilitate mucus clearance (Denehy 1999). Few well-
designed studies have been performed in this specific
area and a more recent animal study (Unoki et al. 2005)
is inappropriately misleading in its recommendations
regarding the use of external rib cage compression in
the ventilated patient. However, care should be taken to
ensure that compressions to the chest wall are terminated
at mid expiratory lung volumes to avoid collapsing the
airways and reducing FRC.
Percussion has been shown to have detrimental effects,
for example arrhythmias and reduced lung compliance in
the critically ill individual (Hammon et al. 1992; Jones
et al. 1992). Despite this, Davis et al. (2001) discovered
that percussion did aid sputum clearance in the copiously-
productive ventilated patient when investigating the effec-
tiveness of continuously turning beds. The use of vibrations
in the intensive therapy unit to facilitate reaeration of
atelectatic areas is not supported radiographically (Stiller
et al. 1996).
Other considerations
While some aspects and combinations of physiotherapy
interventions have been considered in light of available
evidence, other inputs may also form part of the respira-
tory therapist’s role such as that of leading on weaning
protocols (the transfer of the work of breathing from the
ventilator back to the patient). As mentioned previously,
faster weaning episodes may be expected with the imple-
mentation of respiratory therapy-led protocols (Marelich
et al. 2000; MacIntyre 2005).
REHABILITATION FOR THE CRITICAL
CARE POPULATION
This area of physiotherapy practice is gaining greater
emphasis within the critical care environment. There have
been more studies exploring what is involved, who should
receive rehabilitation and the safety of this treatment, with
findings considered below. Additionally, recent guidance
141
 Tidy’s physiotherapy
from NICE, and the appropriateness and effectiveness of
this area of practice are explored.
Who needs critical care
rehabilitation?
This is a very good question and one that is not very easily
answered without having knowledge of the patient’s case
history. The physiotherapist will have detailed knowledge
of their own case load. When assessing and treating the
critical care patient, weakness and rehabilitation needs
must not be forgotten following their critical care stay,
as there may be a deleterious impact for the individual
upon their level of dependency and quality of life
post-discharge.
The reported prevalence of problems in returning to
function varies, but the incidence remains surprising. De
Jonghe et al. (2000) identified that 25.3% of patients
requiring ventilation for longer than seven days had some
form of critical care acquired paresis. The quality of life
and function of patients 1 year after a critical care stay
requiring ventilation for 48 hours or more showed that
54% had restrictions in daily functioning, with walking
and mobility being the most commonly affected (van der
Schaaf et al. 2009a), and 69% were restricted in perform-
ing daily activities, with only 50% having returned to work
(van der Schaaf et al. 2009b). Thus, a high proportion of
patients will need some form of rehabilitation during or
following their intensive care unit stay.
However, when to introduce rehabilitation must also be
considered. A number of studies have looked at when
rehabilitation can begin, depending on neurological,
cardiac and respiratory criteria, and have experienced
minimal problems as a consequence (Stiller and Phillips
2004; Bailey et al. 2007). Stiller and Phillips (2003) rec-
ommended to aim for less than 50% of maximal heart rate
during rehabilitating and a PaO2/FiO2 ratio of more than
300 before commencing rehabilitation. Alternatively,
Bailey et al. (2007) found that adverse events only occurred
in 0.96% of instances using the neurological (response
to stimuli), respiratory (FiO2 above 0.6 and PEEP below
10 cmH2O) and circulatory (absence of orthostatic and
catecholamine drips) assessment criteria.
The effects of weaning the patient from mechanical ven-
tilation must be remembered when deciding whether a
patient is ready for rehabilitative treatment. Rehabilitation
may not be successful when patients have an increased
demand on the respiratory muscles with decreased respira-
tory support. It is suggested that rehabilitation treatments
should take place during periods of higher respiratory
support (Stiller and Phillips 2003).
What is critical care rehabilitation?
Again this is not an easy question to answer as the evi-
dence for rehabilitation and what this should consist of is
142
scarce. Patients can suffer psychological and physical prob-
lems both during and following an intensive care unit
admission. A fundamental component of physiotherapy
practice within the intensive care unit is physical rehabili-
tation but the structure of this varies widely. Treatment
may start with positioning and passive movements in the
unresponsive patient and progress to assisted, active and
resisted exercises when patient cooperation and progress
is obtained. The aims of intervention are those of main-
taining or improving joint range of motion, soft tissue
length, muscle strength and function, and decreasing the
risk of thromboembolism.
There are a wide variety of techniques employed and
frequency of use within the literature. A study by Stiller
et al. (2004) described techniques such as lying to sitting,
sitting to standing, transfers and walking as components
of their global management. Thomas et al. (2009)
included passive rehabilitation, which included hoist and
slide transfers to a chair. Although this included minimal
patient participation, they concluded that these activities
had an important role in the rehabilitation of critically ill
patients. The active rehabilitation included active assisted
and active muscle strengthening exercises along with those
techniques described by Stiller et al. (2004).
Perme and Chandrashekar (2009) described a four-
phase rehabilitation programme with criteria for progress-
ing onto the next phase. The programme encompassed
progressive mobilisation and walking with the progression
based on a patient’s functional capability and ability to
tolerate the prescribed activity. Schweickert et al. (2009)
used passive movements in unresponsive patients, moving
onto active assisted and active exercises when patients
became more aware of treatment. Treatment could then
be advanced to include bed mobility and sitting, progress-
ing onto activities of daily living. They found this strategy
for whole body rehabilitation during interruptions of
sedation in the earliest days of critical illness was safe and
well tolerated.
Guidance and evidence base
The effects of rehabilitation in the critical care setting have
been investigated but with limited detail concerning the
rehabilitation involved, therefore findings have limited
use within clinical practice. Rehabilitation has been found
to significantly improve exercise tolerance testing (Nava
1998), strength (Zanotti et al. 2003; Chiang et al. 2006)
and inspiratory pressures (Nava 1998; Chiang et al. 2006)
in patients during and following mechanical ventilation;
however, the lack of detail of the rehabilitation strategies
used make these findings less applicable to the clinical
setting. Schweickert et al. (2009) discovered that rehabili-
tation during daily sedation stops for patients requiring
mechanical ventilation for more than 72 hours, and
improved return to independent functional status for 59%
of patients in the intervention group, compared with 35%
 Adult spontaneous and conventional mechanical ventilation Chapter 7

of patients in the control group receiving routine care.
Although the control group treatment was not clear, the
rehabilitation strategies involved active assisted exercises
in supine and progressed to walking when appropriate.
These strategies could be applied to physiotherapy practice
in this population.
NICE have recommended that rehabilitation starts as
early as possible for patients at risk and therefore supports
the need of rehabilitation within the critical care setting
(NICE 2009). The guideline development group also rec-
ommended that it was good practice ‘to provide individu-
alised, structured rehabilitation at each key stage of the
patients’ rehabilitation pathway’ for those patients with a
recognised need at assessment. Therefore, these guidelines
not only support a detailed and structured assessment of
rehabilitation needs, but also provision of rehabilitation
within the critical setting and all the way through to post-
discharge care.
There is limited evidence looking at the effect of an
outpatient physiotherapy-led exercise programme for
patients following discharge from the intensive care
unit. McWilliams et al. (2009) assessed the impact of an
outpatient-led rehabilitation programme on exercise
capacity and anxiety and depression scores in a cohort of
adult intensive care survivors. Although this was a small
study and the patients were not randomised, the results
showed improvement in both these parameters. Van der
Schaaf et al. (2009a) led a cross sectional study to look at
restrictions in daily functioning and thereby identify prog-
nostic factors for critically ill patients one year after dis-
charge from the intensive care unit. They concluded that
patients who stayed in the intensive care unit for at least
two days are a potential target population for rehabilita-
tion medicine, but as known prognostic factors had only
limited predictive value for the development of functional
restrictions, further work is necessary in this area to estab-
lish which groups would benefit.

FURTHER READING

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Intensive Care: A Concise Textbook,
second ed. WB Saunders,
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MacIntyre, N.R., Cook, D.J., Ely Jr.,
E.W., et al., 2001. Evidence-based
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MacIntyre, N.R., Epstein, S.K., Carson,
S., et al., 2005. Management of
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Seaton, A., Leitch, A.G., Seaton, D.,
2000. Crofton and Douglas’s
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Tobin, M.J., 1988. Respiratory muscles
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Tobin, M.J., Jubran, A., Laghi F., 2001.
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145
 Chapter
Cardiac rehabilitation
Sushma Sanghvi
CARDIAC REHABILITATION
Physiotherapists are valuable members of the multi-­
disciplinary cardiac rehabilitation team. This chapter
provides important key information about the research
evidence, exercise prescription and planning across the
four phases of cardiac rehabilitation. For in depth infor-
mation about planning and delivering exercise rehabilita-
tion for special conditions such as patients with heart
failure, implanted cardioverter-defibrillators and cardiac
transplantation, the reader is advised to refer to the guide-
lines and texts listed at the end of the chapter.
BACKGROUND
According to the World Health Organization (WHO), an
estimated 17 million people die of cardiovascular disease
(CVD) every year of whom 7.2 million die of coronary
heart disease (CHD) and 5.7 million die of stroke. CVD is
responsible for 10% of disability adjusted life years
(DALYs) lost in low- and middle-income countries and
18% in high-income countries.
According to 2008 statistical data from the British Heart
Foundation (BHF), CHD causes around 88,000 deaths in
the UK every year. It is also the most common cause of
premature death (death before the age of 75) in the UK.
Eighteen per cent of premature deaths in men and 9% of
premature deaths in women are from CHD. Nearly all
deaths from CHD are a result of myocardial infarction
(MI, heart attack). Around 124,000 people in the UK
suffer a MI every year. There are 28,000 new cases of
angina and 27,000 new cases of heart failure every year
in the UK.
Over the last two decades of the twentieth century in the
UK, there was a decline in the death rates from CHD.
8 
In a study by Unal et al. (2004), the authors concluded
that 58% of CHD mortality decline in the 1980s and
1990s was owing to a reduction in major risk factors,
primarily smoking. The remaining 42% of the decline
in mortality was explained by treatments, including
secondary prevention.
There remains considerable variation in the death rates
across the UK. Deaths from CHD are highest in Scotland
and the north of England. While deaths from CHD have
declined overall, the difference between the most deprived
groups and the least deprived groups remains high (5 : 1).
South Asians living in the UK (Indians, Bangladeshis,
Pakistanis and Sri Lankans) have a higher premature death
rate from CHD than average. The death rate is 46% higher
in South Asian men and 51% in South Asian women.
The overall burden of CVD is now far greater as a result
of more people surviving cardiac illnesses and living much
longer than before.
While genetic factors play a part, 80–90% of people
dying of CHD have one or more major risk factors influ-
enced by lifestyle. Physical activity, obesity, smoking and
diabetes are major risk factors for CHD.
Many people find making significant lifestyle changes
difficult, for example, people may be addicted to nicotine.
If someone recently admitted to hospital with CHD needs
to increase the amount of physical activity they undertake
regularly, not only do they need to be well motivated but
they and their families need to be confident that the exer-
cise is safe.
Like all major illnesses, CHD has major physical, psy-
chological and behavioural impacts on patients and their
families. For some, the psychological consequences can be
persistent and disabling. They can also be a barrier to
making the lifestyle changes necessary to reduce the sub-
sequent cardiac risk. For example, people with CHD can
be afraid to take exercise or participate fully in their daily
activities for fear of damaging their heart. After admission
to the hospital, maybe following a MI or for coronary
147
 Tidy’s physiotherapy
revascularisation, the advice and treatment provision in
primary care may not always be sufficient. Many people
require more intensive help to understand their illness and
treatment to attain the lifestyle changes and to regain their
confidence so that they can enjoy the best possible physi-
cal, mental and emotional health, and return to as normal
a life as possible.
WHAT IS CARDIAC REHABILITATION?
The WHO defines cardiac rehabilitation as:
The rehabilitation of cardiac patients is the sum
of activities required to influence favourably the
underlying cause of the disease, as well as the
best possible physical, mental and social
conditions, so that they may, by their own efforts,
preserve or resume when lost, as normal a place
as possible in the community. Rehabilitation
cannot be regarded as an isolated form of
therapy, but must be integrated with the whole
treatment, of which it forms only one facet.
(WHO 1993)
Cardiac rehabilitation is a comprehensive intervention
that offers education, exercise and psychosocial support
for patients with CHD and their families and is delivered
by many specialist health professionals. Cardiac rehabili-
tation can promote recovery, enable patients to achieve
and maintain better health, and reduce the risk of death
in people who have heart disease.
Definition
Cardiac rehabilitation is the process by which patients
with cardiac disease, in partnership with a
multidisciplinary team of health professionals, are
encouraged and supported to achieve and maintain
optimal physical and psychosocial health.
BACPR (2002)
Research evidence for cardiac
rehabilitation
When well provided and when people are offered compre-
hensive and tailored help with lifestyle modification
involving exercise training, education and psychological
input, cardiac rehabilitation can make a substantial differ-
ence in reducing mortality by as much as 20–25% over
three years.
148
Table 8.1  Cochrane review 2004: meta-analyses of
8440 myocardial infarction, revascularisation and
ischaemic heart disease patients
Exercise-only 27% reduction all cause mortality
rehabilitation 31% reduction in cardiac mortality
Comprehensive 13% reduction all cause mortality
rehabilitation 26% reduction cardiac mortality
The Cochrane Review 2004 (Jolliffe et al. 2004) (Table
8.1) established the importance of exercise-based cardiac
rehabilitation. Cardiac mortality was reduced by 31% in
the exercise-only cardiac rehabilitation and by 26% in
comprehensive cardiac rehabilitation groups.
The research has been focussed around phase III of reha-
bilitation and in patients after MI and revascularisation.
Many studies still include only low risk, male, Cauca-
sian, middle-aged MI patients and enroll only a small
number of women, the elderly and ethnic minorities.
Other cardiac patient groups, such as those following
cardiac surgery, heart failure or heart transplantation, are
excluded, thereby limiting the generalisability of the
results.
Systematic reviews for chronic heart failure have dem-
onstrated that exercise-based cardiac rehabilitation reduces
mortality, increases the quality of life and that exercise is
safe in this group of patients.
Evidence for physical activity and exercise
The WHO estimates that around 6% of all disease burden
and around 30% of CHD burden to be caused by physical
inactivity (WHO 2010). Physical activity levels are low
in the UK. The Health Survey for England data (2008)
show that only 39% of men and 29% of women meet
the government guidelines of 30 minutes of moderate
physical activity five or more times a week. The proportion
of both men and women who met the recommendations
decreased with age. Therefore, structured exercise as a
therapeutic intervention is essential to the cardiac reha­
bilitation programme.
Evidence for education and psychosocial
interventions
Psychological outcomes have been less well studied
than the physical and functional effects of exercise train-
ing, and less well documented. It is likely that many of
the psychological benefits are attributable to group
activities, peer support and access to professional advice.
There is difficulty in measuring outcomes for these
interventions. Questionnaires have been used widely to
measure quality of life and health status. Both generic (e.g.
Short Form 36 (SF36)) or disease-specific (e.g. Quality

of life after MI (QLMI)) have been used. Short-term ben-
efits have been observed in studies using disease-specific
questionnaires.
Patient groups in cardiac
rehabilitation
Typically, patients following an acute MI and coronary
artery by-pass graft (CABG) surgery have been referred for
cardiac rehabilitation. The National Service Framework
recommends that cardiac rehabilitation should be availa-
ble to people manifesting CHD in various forms. Many
more groups are now included in both comprehensive and
exercise-based rehabilitation.
Post-revascularisation
The number of patients receiving percutaneous translumi-
nous coronary angioplasty (PTCA) and stenting are
increasing. Education for lifestyle modification and exer-
cise training is proven to be beneficial on physiological
and psychosocial risk factors.
Stable angina
Cardiac rehabilitation improves the management of symp-
toms and exercise training assists in raising the angina
threshold so patients are able to do more before they
experience angina.
Chronic heart failure
With the advances in the management of CHD, the
number of patients presenting with chronic heart
failure are increasing. Exercise-based cardiac rehabilitation
is beneficial in improving exercise capacity, reduction
of symptoms and improving quality of life. Patients
with mild-to-moderate heart failure show the largest
improvements.
Special needs groups
An important drawback in most research is the lack of
female and elderly patients, and patients’ ethnic back-
grounds are rarely reported. These under-represented
groups need special attention.
Women
Incidence of CHD tends to be higher in men; however, this
difference decreases with increasing age. According to the
BHF statistics 2010 (BHF 2010), every year 44,000 women
in the UK have a MI. Uptake of cardiac rehabilitation
among women is low. When women attend cardiac reha-
bilitation programmes, the outcomes are as good as, or
Cardiac rehabilitation Chapter 8
better than, for men. Their need may be greater as they
suffer greater loss of function in relation to return to work,
activity and sexuality, and experience high levels of anxiety
and depression. More gender-specific information, indi-
vidualised and flexible programmes, and suitable environ-
ment are required to address the specific needs of this
group.
Older adults
Over half of all MIs occur in people over the age of 70
years and this is going to rise further as the number of
older people in the total population increases. Disability
rates are very high in these patient populations, particu-
larly in women and in patients with angina or chronic
heart failure. The presence of depression is also a determi-
nant of poor physical functioning. Cardiac rehabilitation
has been demonstrated to be safe and to improve aerobic
capacity and muscle strength in older adults. Elderly
people can derive similar benefits from a comprehensive
menu-based cardiac rehabilitation programme. Issues of
access, transport, timings and flexible programmes need
to be addressed to meet the requirement of this patient
population.
Ethnic groups
The incidence of CHD is much higher in some ethnic
communities (e.g. South Asians). It has been suggested
that people from ethnic minorities are less likely to be
referred and join cardiac rehabilitation programmes.
While planning strategies for rehabilitation for ethnic
groups, their heterogeneity and cultural and linguistic
needs must be acknowledged. When a behavioural change
is required, it is crucial that the message is clearly under-
stood. Knowledge of the cultural influences on physical
activity and dietary practices would be beneficial to the
patient. Similarly, awareness of health education material
in appropriate languages can enhance the quality of
service. It will help to involve health professionals from
similar cultural backgrounds to develop and evaluate
progress.
A variety of settings appropriate to the targeted com-
munities can be used, for example community centres,
temples, mosques, churches, health centres, etc. Involve-
ment of the family and the younger generation is vital.
Other groups
For these groups, individualised assessment and risk strati-
fication is essential.
Cardiac transplant
This group is relatively small. There is some evidence that
exercise-based cardiac rehabilitation improves exercise
tolerance in this group of patients.
149
 Tidy’s physiotherapy
Valve surgery
Supervised exercise training in comprehensive cardiac
rehabilitation is beneficial in improving functional capac-
ity, reducing symptoms and improving the quality of life
in this patient group.
Congenital heart disease
This group includes young people and children. Super-
vised exercises improve exercise capacity and psychologi-
cal function in this patient group.
Implanted cardioverter-defibrillators
The number of patients with implanted cardioverter-
defibrillators in a cardiac rehabilitation programme may
be small; however, comprehensive cardiac rehabilitation
is safe and improves exercise ability and psychological
well-being significantly.
Provision in the UK and
cost-effectiveness
The overall level of provision of cardiac rehabilitation pro-
grammes in the UK has increased rapidly in the last 20
years. Current data from the National Audit of Cardiac
Rehabilitation reveal the number of programmes at 395.
The national service framework for CHD has advocated
the use of disease registers in primary care to provide long-
term follow up of patients with CHD and has set standards
and milestones for secondary prevention.
There are huge variations in programme types, duration,
frequency and intensity of exercise training. Many centres
are delivering the service in primary care, and menu-based
programmes are provided by a multi-disciplinary team.
A UK estimate suggests a cost of £6900 per Quality
Adjusted Life Years (QALY) and a cost per life year gained
of £15,700 three years after cardiac rehabilitation. This
offers good value compared with many other treatments
currently provided by the National Health Service (NHS).
COMPONENTS OF CARDIAC
REHABILITATION
• Risk factor assessment and modification.
• Education.
• Exercise.
• Psychosocial support.
Operation and delivery
It transpires that cardiac rehabilitation is really a con­
tinuum of care from the time the patient is admitted until
150
discharge and extends to outpatient care, as well as long-
term follow-up in the community. Patient care is shared
with the cardiology team, of which cardiac rehabilitation
forms an essential part. Cardiology management includes
patient assessment and risk stratification (predicting the
likelihood of recurrence of cardiac events and disease
prognosis). The patient also undergoes diagnostic tests
and drug therapy, and may need revascularisation, such as
angioplasty or a bypass grafting as appropriate.
Traditionally, cardiac rehabilitation is divided into four
phases, progressing from the acute hospital admission
stage to long-term maintenance of lifestyle change.
Phase I: inpatient period.
Phase II: early post-discharge period.
Phase III: supervised outpatient programme, including
structured exercise.
Phase IV: long-term follow-up/maintenance in primary
care.
Phase I: Inpatient period
Cardiac rehabilitation is offered as soon as it is practical
as an integral part of care to someone who is admitted
(or who is planned to be admitted) to hospital with CHD.
It includes:
• assessment of physical, psychological and social
needs;
• negotiation of a written informal plan for meeting
these identified needs;
• initial advice on lifestyle, e.g. smoking cessation,
physical activity (including sexual activity), diet,
alcohol consumption and employment;
• mobilisation;
• education about prescribed medication, its benefits
and possible side effects;
• involvement of relevant informal carer;
• provision of locally written information about
cardiac rehabilitation;
• discharge planning.
Phase II: Early post-discharge period
This service shows variation in different regions and can
vary from as little as a telephone helpline to group
sessions or individual appointments (Figure 8.1). The
National Service Framework recommendation includes:
• comprehensive assessment of cardiac risk, including
physical, psychological and social needs for cardiac
rehabilitation, and a review of the initial plan to
meet these needs;
• provision of lifestyle advice and psychological
interventions according to the agreed plan by the
multi-disciplinary team;
• maintaining involvement of relevant informal carer;
• home visits, if appropriate.

B
Figure 8.1  Assessment with cardiac nurse.
Phase III: Supervised outpatient programme,
including structured exercise
Traditionally, this phase is well set up in the form of an
outpatient hospital-based programme, although more
services are now shifted into primary care. It includes:
• risk stratification and identification of the high-,
medium- and low-risk patient for exercise;
• individualised progressive exercise prescription and
supervised exercise sessions which vary from 4–12
weeks in different regions;
• re-evaluation of risk factors for CHD and health
promotion advice and education (Figure 8.2).
• psychosocial interventions, such as stress
management, counselling and vocational guidance.
Phase IV: Long-term follow-up/maintenance
in primary care
This phase is now well set up in many districts, with
emphasis on provision of exercise sessions available in
community or leisure centres. Specialist training to exer-
cise CHD patients in the community is available to the
Cardiac rehabilitation Chapter 8
Figure 8.2  Physiotherapist measuring the height to assess
body mass index.
exercise instructors by the British Association for Cardio-
vascular Prevention and Rehabilitation (BACPR).
Phase IV includes:
• long-term maintenance of individual goals;
• professional monitoring of clinical status and
follow-up of general progress;
• ongoing psychosocial support and support groups.
Cardiac rehabilitation team
The cardiac rehabilitation package individualised for
each patient requires expertise and skills from a multi-
disciplinary collaborative team of professionals (Figure
8.4). The team includes a cardiologist and staff from
nursing, physiotherapy, dietetics, pharmacy, occupational
therapy and psychology with training in cardiac rehabilita-
tion. Continuation of care in the community involves the
primary healthcare team that is the general practitioner
and cardiac nurse, phase IV exercise specialist and a link
from a local cardiac patient support group (Figure 8.3).
The role of the physiotherapist
Physiotherapists have the knowledge, assessment skills
and clinical reasoning, combined with evidence-based
approach to treatment, to undertake the rehabilitation
management of patients with multi-pathology problems.
Physiotherapists are also trained to run group sessions and
classes. Hence, the role of the physiotherapist within the
151
 Tidy’s physiotherapy

multi-disciplinary team should focus on exercise prescrip-

tion, training and education in phases I–III. The modifica-
tion in exercise prescription needs to be discussed with
medical and nursing team members. In a group setting
where exercise is delivered to CHD patients, teamwork
and liaison with other team members who are aware of
patients’ clinical and psychosocial issues is essential.
Professional development
The Association of Chartered Physiotherapists in Cardiac
Rehabilitation (ACPICR) recommends that physiotherapists
wishing to specialise in this area should refer to the ACPICR
competences for the exercise component of phase III cardiac
rehabilitation and the Skills for Health: Coronary Heart
Disease document (ACPICR 2008). They should consider
undertaking professional development in exercise
physiology and exercise prescription in cardiovascular
disease. Use of clinical and cardiac networks to share
experiences, for example interactive CSP (www.csp.org.uk),
is recommended.

BENEFITS OF EXERCISE TRAINING

A Definition

The term ‘exercise training’ applies to a programme of

repeated exercises undertaken at a guided or prescribed
intensity and frequency over a period of time, usually
several weeks. It is based upon aerobic exercise designed
to improve physical performance at both maximal and
submaximal levels. It may be of low, moderate or high
intensity, and may also include resistance training.

Research confirms that exercise training improves physical

B ing in cardiac patients (Tables 8.2 and 8.4). It shows a
Figure 8.3  Dietician addressing a group of patients
attending phase III cardiac rehabilitation programme.
Menu-based Needs driven
performance (exercise tolerance, muscular strength and
symptoms), psychological functioning (anxiety, depres-
sion and well-being), and social adaptation and function-
reduction in mortality, morbidity, recurrent events and
hospital readmissions. It is also found to have a positive
impact on patients’ physical ability to exercise (Table 8.3).
Therefore, exercise training as a therapeutic intervention is
central to the cardiac rehabilitation programme.

Physiotherapist Nurse Social

worker
Table 8.2  Physiological benefits of exercise training
Other in chronic heart disease patients (risk factors
modification)
Occupational
Pharmacist Patient
therapist Reduction in systolic and diastolic blood pressures
Reduction in % body fat, increase in lean body mass
Reduction in fibrinogen levels and platelet aggregation
Increase in high-density lipoprotein, reduction in
triglycerides
Dietician Cardiologist Psychologist
Increased insulin sensitivity, improved glucose-insulin
dynamics
Figure 8.4  The cardiac rehabilitation team.

152

Table 8.3  Symptomatic benefits of exercise training
in chronic heart disease patients
Reduced risk of arrhythmias
Increased ischaemic threshold
Increased angina threshold
Improved coronary perfusion
Reduction in ST wave changes
Reduced angina episodes/shortness of breath
Table 8.4  Psychosocial benefits of exercise in chronic
heart disease patients
Reduction in anxiety and depression
Improved sleep patterns
Improved sense of well-being
Restoration of self-confidence
Reduction in illness behaviour
Improved social communication
Return to daily activities/hobbies
Resumption of sex life
Return to work/vocation
Compliance with other risk factors
PHYSIOLOGICAL ADAPTATIONS TO
EXERCISE TRAINING IN HEALTHY
INDIVIDUALS AND CORONARY
HEART DISEASE PATIENTS
In healthy individuals physiological adaptations to aerobic
exercise training are central (cardiac) and peripheral
(skeletal muscle and vascular).
Adaptations at submaximal level   VO2 max.
of aerobic exercise
Adaptations at the submaximal level of aerobic exercise
are reduction in heart rate (HR) owing to a decrease in
sympathetic activity and increase in parasympathetic activ-
ity (vagal tone). The stroke volume increases owing to
greater left ventricular filling and an increase in left ven-
tricular mass. A decrease in the resting HR and blood
pressure (BP) implies reduced myocardial oxygen demand.
Also, the period of diastole is increased allowing greater
time for blood to flow into the coronary circulation.
Cardiac output [CO = HR (heart rate) × SV (stroke
volume)] must always match metabolic demand, but does
so with reduced HR and increased stroke volume. Systolic
BP (SBP) decreases and there is redistribution of blood
flow to trained skeletal muscle and other tissues. Circulat-
ing catecholamines decrease and the arterio-venous
oxygen difference increases.
Cardiac rehabilitation Chapter 8
Central changes as a result of aerobic
exercise training
• Increased stroke volume.
• Increased left ventricular mass.
• Increased chamber size.
• Increased total blood volume.
• Decreased total peripheral resistance during maximal
exercise.
Peripheral changes as a result of aerobic
exercise training
• Increased arterio-venous oxygen difference.
• Increased number and size of mitochondria.
• Increased oxidative enzyme activity.
• Improved capillarisation.
• Increased myoglobin.
Key point
As a result of aerobic training there are functional and
structural changes in skeletal muscle, the heart and the
circulation. These changes improve the circulatory
system’s capacity to transport oxygen to the working
muscles (central changes) and the capacity of skeletal
muscle to extract and use oxygen (peripheral changes).
Increase in VO2 max
Oxygen consumption (VO2) is expressed either in absolute
terms as litres per minute (L.min−1) or relative to body
weight as mL per kg per minute (mL.kg−1.min−1). VO2 max
is the highest rate of oxygen consumption attainable
during maximal exercise. Aerobic training increases
In relative terms, an individual walking at 4 miles per
hour uses 17.5 mL of oxygen per kg of bodyweight per
minute. In absolute terms, a man weighing 70 kg will use
1225 mL or 1.2 L per minute.
Key point
The significance of increased VO2 max is a reduction in
physiological stress evoked by submaximal activity and
not the ability to perform maximal bouts of exercise.
In CHD patients, the increase in VO2 max is predominantly
a result of peripheral adaptations. Central changes are
associated with long periods of high intensity training.
Although central changes have been shown with high
intensity training in CHD patients in some studies, in the
153
 Tidy’s physiotherapy
Key point
Aerobic exercise training at moderate intensity confers
benefits to CHD patients by peripheral adaptations.
conventional cardiac rehabilitation programmes this
regime is not suitable. Physical performance improve-
ments are better seen in patients with low exercise
tolerance.
ASSESSMENT FOR EXERCISE
PRESCRIPTION
A thorough assessment is essential in order to plan an
individualised and safe exercise prescription for cardiac
patients and should include the following:
• a detailed history of the present condition and
clinical presentation;
• previous levels of activity and exercise;
• physical limitations and disabilities;
• signs and symptoms;
• risk factor assessment/profile;
• screening for relative contraindications;
• risk stratification;
• functional capacity test;
• psychosocial assessment: objectives, beliefs,
knowledge, interests, ethnicity;
• patient goals and expectations.
Contraindications to exercise
• Unstable angina.
• Resting SBP >200 mmHg or resting diastolic BP
(DBP) >110 mmHg.
• Orthostatic BP drop >20 mmHg with
symptoms.
• Critical aortic stenosis.
• Acute systemic illness or fever.
• Uncontrolled atrial or ventricular
arrhythmias.
• Uncontrolled sinus tachycardia.
• Uncompensated chronic heart failure.
• Third degree heart block.
• Active pericarditis or myocarditis.
• Recent embolism.
• Thrombophlebitis.
• Resting ST segment displacement >2 mm on
electrocardiograph (ECG).
• Uncontrolled diabetes (resting blood glucose
>400 mg/dL).
154
EXERCISE PRESCRIPTION: THE FITT
PRINCIPLE
To develop an individual exercise training programme,
factors known as the FITT principles are considered.
• Frequency
• Intensity
• Time (duration)
• Type of exercise
Frequency, time and type or modes of exercise are
explained later in the chapter with activities in different
phases of cardiac rehabilitation.
Intensity of exercise
The risk of developing arrhythmias or adverse events such
as an acute MI is increased in cardiac patients with vigor-
ous activity. Low-to-moderate intensity exercise training
can produce beneficial changes in functional capacity,
cardiac function, coronary risk factors, psychosocial well-
being and possibly improve survival in patients with CHD.
For patients with low functional capacity, frequent and
short duration exercise stimulus incorporated throughout
the day may be advisable.
Intensity is prescribed and monitored by several meth­
ods which can be used independently or in combination
with one another.
Heart rate
Each individual patient should have his/her training HR
calculated based on thorough assessment and risk stratifi-
cation. The training intensities for most patients range
between 60% and 75% of the maximum HR for the
majority of the population group. The more complex
patient will require lower intensities (40–50%); hence,
appropriate adjustments to these calculations will be
required.
In ideal circumstances, when available, the training HR
is obtained from a maximum or symptom limited exercise
ECG test (exercise tolerance test (ETT)). The training HR
should be set at 60–75% of maximal HR or 20 beats below
the HR at which the symptoms appeared, and should be
monitored throughout the exercise session. However, ETT
information is not always available to the cardiac rehabili-
tation team and other methods for determining the train-
ing intensity are used frequently.
Using HR in isolation as a measure of exercise intensity
has a number of limitations; hence, other methods of
monitoring intensity should be used in addition. This
includes the use of validated rating of perceived exertion
scale (RPE) and direct clinical observation for signs of
exertion.
Heart rate can remain one of the appropriate inten­
sity markers, even when patients are influenced by
 Cardiac rehabilitation Chapter 8

chronotrophic medication, such as beta-blockers. In this HRR is calculated thus:

instance, the resting HR and the maximal HR are reduced
by 20–40 beats per minute and the target HR can be recal-
culated on this basis.
Age-adjusted predicted maximum heart
rate formula
This formula uses a predicted maximum heart rate based
on age (220 – age) and, as such, can have an error margin
of as much as ± 10 beats per minute.
A percentage of this predicted maximum is selected
based on the assessment findings.
Example
• Patient A (low risk and uncomplicated) is 70 years of
age.
• Maximum age predicted HR = 220 − 70 = 150.
60–75% of predicted maximum HR:
0.60 × 150 = 90
0.75 × 150 = 112.
• Thus, training heart rate = 90 − 112 beats per
minute.
• HRR = maximum HR − resting HR;
• training intensity is selected and calculated, i.e.
50–70% HRR;
• resting HR is added to HRR percentage.
Rating of perceived exertion
Patients need to develop the ability to perceive their exer-
tion while exercising. In other words, they should feel the
physical sensation of how hard they are working so that
they know the safe limits to which they can exert them-
selves. In the early stages of rehabilitation, the physiother-
apist assists using the HR monitoring method and by
setting the exercise circuit at a specific work rate and, most
importantly, by observation of the patients’ response to
exercise. On the 6–20 Borg rating of perceived exertion
(RPE) scale (Table 8.5), a rating of 12–13 (or 3–4 on the
CR-10 scale; Table 8.6) corresponds to 60% VO2 max or 60%
of HRR. A rating of 15 (or 6–7 on the CR-10 scale) cor-
responds to 75% of VO2 max or HRR.
In moderate submaximal exercise muscular sensations
and breathlessness relate very closely to the exercise stimu-
lus and so the RPE scale is advised in cardiac rehabilita-
tion. The CR-10 scale was developed to focus more on

Karvonen formula (heart rate reserve)

Table 8.5  The Borg RPE scale (Borg 1998)
This formula assumes access to a true observed maxi­
mum HR. This may be gained, for example, by an ECG 6
tolerance test. This formula is advantageous in that it
accounts for the individual’s resting HR. A percentage of 7 Very, very light
this is selected based on the assessment findings, noting
8
that 50–70% of HR reserve (HRR) is equivalent to 60–75%
of maximum HR. 9 Very light

10

11 Fairly light
Example
12
• Patient B (low risk and uncomplicated) has a resting
13 Somewhat hard
HR of 65 beats per minute (bpm) and achieves a
maximum HR of 160 bpm during an ECG exercise 14
test. The intensity of training following assessment
has been set at 50–70% of HRR. 15 Hard
• Calculation of HRR = 160 − 65 = 95. 16
• Selection of % of HRR:
17 Very hard
50% of HRR = 0.50 × 95 = 47.5;
70% of HRR = 0.70 × 95 = 66.5. 18
• Add resting HR:
19 Very, very hard
47.5 + 65 = 112.5;
66.5 + 65 = 131.5. 20
• Thus, training heart rate = 112–131 bpm.
© Gunnar Borg 1970, 1985, 1994, 1998.

155
 Tidy’s physiotherapy

Table 8.6  The Borg category ratio (CR-10) scale Table 8.7  Energy costs of leisure activities
(Borg 1998)
Activity METs (min.) METs (max.)
0 Nothing at all No ‘1’
Cycling
0.3
5 mph 2 3
0.5 Very, very weak Just noticeable
10 mph 5 6
0.7
13 mph 8 9
1 Very weak
Dancing
1.5
(ballroom) 4 5
2 Weak Light
(aerobic) 6 9
2.5
Skipping
3 Moderate
<80/min 8 10
4
120–140/min 11 11
5 Strong Heavy
Swimming
6
(breast stroke) 8 9
7 Very strong
(freestyle) 9 10
8
Tennis 4 9
9
Walking
10 Extremely strong ’Strongest 1’
1 mph 1 3
11
3 mph 3 3.5
≤
3.5 mph 3.5 4
• Absolute maximum Highest possible
4 mph 5 6
© Gunner Borg 1981, 1982, 1999.
METs = metabolic equivalent; mph = miles per hour.

rating individual sensations of strain, exertion or pain.

Thus, if pain, breathlessness or localised muscle fatigue is
the dominant sensation the CR-10 scale should be used.
Clinical note
Heart rate monitoring with RPE and observation of the
patient during the exercise is an effective way of
monitoring exercise intensity.
Metabolic equivalent
Metabolic equivalent (MET) relates to the rate of the
body’s oxygen uptake for a given activity as a multiple of
resting VO2. On average, an individual utilises 3.5 mL
of O2 per kg of body weight per minute (ml.kg−1.min−1).
Therefore, one MET equals a VO2 of 3.5 ml.kg−1.min−1.
MET value is assigned to an activity by measuring the VO2
for that activity.
The MET values are reported on the ETT. This informa-
tion is useful for the cardiac rehabilitation physiotherapist
for prescribing intensity, as well as to identify the func-
tional capacity of the patient. For example, a patient with
a peak capacity of seven METs cannot be prescribed skip-
ping (8–10 METs). An individual’s exercises can be pre-
scribed and regulated by choice of activities according to
the MET values for them (see Table 8.5). (Please also refer
to functional capacity described later in the chapter.)
If an individual walking at 3 miles per hour reports his/
her exertion as 12–13 on the RPE scale (12–13 RPE cor-
responds to 60% of VO2 max), then planning activities of
comparable MET value in his/her exercise prescription will
provide him/her with the appropriate training stimulus.
The MET values are estimated and an individual may be
working slightly above or below the estimated MET value
for a particular task. The variability depends on the com-
plexity of the task. Table 8.7 gives the minimal and
maximal activity values. Walking is a complex activity

156

which requires balance and use of arm and trunk move-
ments, and, hence, there is variation in the MET value.
Frequency
Exercise training 2–3 times weekly (e.g. two supervised
classes and one home circuit) for phase III is recom-
mended. Exercising 2–3 times per week for a minimum of
8 weeks produces physiological and psychosocial adapta-
tions. However, it should be remembered that to gain the
optimum benefits patients will need ongoing exposure to
exercise. Phase III should be seen as the beginning of these
changes and after completion patients should be referred
to phase IV for continuation and progression. The ulti-
mate aim is to promote life-long adherence to the indi-
vidual’s exercise behaviour.
Time
The conditioning phase (aerobic exercise training) in a
phase III cardiac rehabilitation programme should last
between 20 and 30 minutes. This should be in addition
to the warm-up and cool-down.
Type
Training activity needs to be aerobic and can be delivered
in many ways. Initially, endurance training is desirable for
CHD patients. Within an individual prescription, incorpo-
rating a variety of exercise types will optimise peripheral
adaptation, reduce the likelihood of overuse injuries and
will enhance motivation and compliance.
RISK STRATIFICATION
Exercise-based cardiac rehabilitation is associated with a
reduction in coronary mortality and morbidity. As a result
of novel treatment approaches now available to CHD
patients and because of the improvement in the manage-
ment of cardiac patients, the type and number of patients
referred for cardiac rehabilitation is increasing.
The risk of adverse cardiac events during exercise is
small. In supervised exercise programmes, the risk of
exercise-related cardiac events is also small. However, it is
essential that the cardiac rehabilitation team responsible
for delivering the exercise programme recognise the likeli-
hood of exercise related incidents and ensure that all
reasonable and necessary steps are taken to deliver safe
and effective exercise prescription to the patients.
Increased myocardial demands of vigorous exercise can
precipitate arrhythmias. Risk is increased with extensive
cardiac damage, residual ischaemia and ventricular ar­­
rhythmias on exercise. All patients should be assessed and
risk stratified prior to recruitment to the exercise compo-
nent of cardiac rehabilitation.
Cardiac rehabilitation Chapter 8
Clinical note
The term risk stratification for the exercise professional in
cardiac rehabilitation implies thorough evaluation of the
patient to assess the degree of risk of further cardiac
events associated with exercise. This allows the exercise
professional to guide patient management for exercise
prescription, monitoring and progression appropriately.
The information required for assessment should include
the following:
• diagnosis and the site and size of infarct or surgery
details, as appropriate;
• current cardiac status;
• results of investigations, e.g. ECG exercise test, ECG
report, angiogram;
• current medication;
• recovery and activity levels since discharge, symptoms;
• past medical history, including musculoskeletal,
respiratory and neurological problems;
• CHD risk factors;
• psychosocial status.
Classification
The patients are risk stratified into low-, medium- and
high-risk groups depending on their current cardiac status.
This includes the extent of myocardial damage, previous
history of MI, complications and associated signs and
symptoms. The main risk to patients attending the exer-
cise component of cardiac rehabilitation is ventricular
fibrillation. Extensive myocardial damage, residual ischae-
mia, significant ECG changes, ST segment depression or
arrhythmias on exercise are the key factors when predict-
ing the risk.
The risk classification given below is based on the guide-
lines from the American Association of CardioVascular
and Pulmonary Rehabilitation (AACVPR 2006).
High risk
The patient is classified at high risk when any one of the
risk factors are present:
• decreased left ventricular function (ejection fraction
<40%);
• complex arrhythmias at rest or appearing or
increasing during exercise testing and recovery;
• presence of angina or other significant symptoms,
such as unusual shortness of breath or dizziness at
low levels of exertion (<5 METS) or during recovery;
• high levels of silent ischaemia (ST segment depression
≥ 2 mm from baseline) during exercise testing or
recovery;
157
 Tidy’s physiotherapy
• abnormal haemodynamics with exercise (especially
decrease in SBP during exercise or recovery – severe
post-exercise hypotension);
• MI or revascularisation procedure complicated by
congestive heart failure, cardiogenic shock and
complex arrhythmias;
• survivor of cardiac arrest or sudden death;
• clinically significant depression.
Moderate risk
The patient is classified as moderate risk when he/she can
meet neither the high nor the low risk criteria.
• Moderately impaired left ventricular function
(ejection fraction 40–49%).
• Presence of angina or other significant symptoms
such as unusual shortness of breath or dizziness
occurring only at high levels of exertion (≥7 METS).
• Mild-to-moderate level of silent ischaemia (ST
segment depression ≤2 mm from baseline) during
exercise testing or recovery.
• Functional capacity <5 METS.
Low risk
The patient is classified as low risk when each of the risk
factors listed below are present:
• no left ventricular dysfunction (ejection fraction
>50%);
• no resting or exercise-induced complex arrhythmias;
• absence of angina or other significant symptoms,
such as unusual shortness of breath or dizziness
during exercise testing and recovery;
• uncomplicated MI, CABG, PTCA;
• normal haemodynamics with exercise testing and
recovery;
• functional capacity ≥7 METS;
• absence of clinical depression.
Functional capacity
Functional capacity is a strong and independent risk factor
of all-cause and cardiovascular mortality, and the one that
can be improved by training. A low functional capacity of
less than six METs indicates a high mortality group and
functional capacity of greater than ten METs indicates
excellent survival, regardless of occlusive coronary disease
or left ventricular function.
Functional exercise testing
The most widely recognised measure of cardiopulmonary
fitness is the aerobic capacity or maximal oxygen con-
sumption (VO2 max). This variable is defined as the highest
158
rate of oxygen transport and use that can be achieved at
maximal physical exertion. Thus, it is an expression of the
functional health of the combined cardiovascular, pulmo-
nary and skeletal muscle systems. It may be used to pre-
scribe an appropriate training intensity in rehabilitation
programmes and to identify improvements in endurance
fitness. Determination of VO2 peak during cardiopulmo-
nary exercise testing provides an objective and reproduci-
ble assessment of functional capacity in patients with
cardiac disease. In clinical practice, VO2 peak is predicted or
estimated from the treadmill speed and per cent grade,
and expressed as METs. Thus, ETT can produce an esti-
mated MET value to assess the patient’s response to exer-
cise, to guide risk stratification and exercise prescription.
It would also serve as an objective outcome measure of the
impact of exercise programme on functional capacity. An
ETT is strongly recommended 3–6 weeks post-event.
ETT can give the following information:
• HRs and exercise level at peak exercise;
• symptoms and/or ECG changes;
• RPE;
• BP response to exercise;
• MET level achieved at training HRs (e.g. at 60–75%
of HR max).
MET values can also be estimated from submaximal
protocols recommended for assessing functional capacity.
These are externally paced field exercise tests, such as the
step test, shuttle walk test and cycle ergometry.
The Chester step test is a submaximal multi-stage test
lasting ten minutes with a choice of four step heights.
The shuttle walking test (SWT) is a low cost, simple
alternative to exercise testing that informs the rehabilita-
tion team on a suitable exercise programme and appropri-
ate training HR, and allows assessment of progress during
cardiac rehabilitation. The limitation of SWT is that it
is not suitable for people with higher baseline fitness
level. Also, it may not be sensitive to change demonstrat-
ing improvements in functional capacity in the older
cardiac population with coexisting pathologies by incre-
mental walking. Thus a variety of outcome measures
may be required for the patient population of cardiac
rehabilitation.
The information obtained from the risk classification is
used to determine baseline fitness level, exercise prescrip-
tion, exercise progression, staff–patient ratio, and whether
the site of the exercise programme is supervised or unsu-
pervised and based in the hospital or community.
EXERCISE PROGRAMMING
Patients should participate in an induction prior to under-
taking the Phase III exercise component of cardiac
rehabilitation.
 Cardiac rehabilitation Chapter 8

Patients should not take part if they present with:
• fever and acute systemic illness;
• unresolved unstable angina;
• resting systolic blood pressure >200, diastolic blood
pressure >110;
• significant unexpected drop in blood pressure;
• tachycardia >100;
• new symptoms of shortness of breath, palpitations,
dizziness or lethargy;
• recent embolism;
• thrombophlebitis;
• uncontrolled diabetes (should be assessed with local
protocol and on a case-by-case basis);
• severe respiratory, orthopaedic or metabolic
condition that would limit the exercise ability.
Warm-up
Strenuous exercise without previous warm-up can produce
ischaemic ST segment changes and arrhythmias even in
healthy adults.
are raised and lowered, circled backwards and forwards,
and the lumbar and thoracic spine mobilised by bending
sideways and turning). This ensures that the joints are well
lubricated and blood flow to the structures surrounding
the joints increases, allowing full range of movement.
Stretching the large muscles will assist mobilisation.
Muscles which are prone to adaptive shortening owing
to cardiac surgery or as a result of the ageing process
should be stretched for about ten seconds. While holding
a stretch it is important to keep the rest of the body
moving to maintain the pulse rise and to avoid pooling of
blood in the lower extremities (venous pooling).
Specific movements
Specific exercises that mimic the movements of prescribed
activity at low intensity levels will assist the preparation
for conditioning phase by activating the neuromuscular
pathways (e.g. alternate legs to side before side-stepping)
(Figures 8.5 and Figure 8.6).

Key point

For older adults and the cardiac patients, warm-up must be

more gradual than for an apparently healthy population.

The warm-up is the preparatory phase of the exercise

session. A well planned and effectively carried out warm-up
will improve the exercise performance and optimises the
safety and effectiveness of the exercise session. For cardiac
patients, warm-ups should be of at least 15 minutes dura-
tion. This prepares the cardiovascular system for the exer-
cise activity. It allows a gradual increase in myocardial
blood supply by vasodilation of the coronary arteries and
achieves a gradual rise in aortic pressure. This reduces the Figure 8.5  A group of phase III patients doing ‘warm-up’
risk of provoking ischaemia and arrhythmias. It also pre- stretches.
pares the mind by focussing the participants’ attention on
the activity ahead.
The warm-up consists of pulse-raising exercises, mobi-
lising major joints and stretching – specific warm-up
movements.

Pulse-raising exercises
These include rhythmic movements, initially of lower
limbs (e.g. walking forwards and back, stepping, side-
stepping, step backs, etc.) gradually increasing the HR and
blood flow of the active muscles.

Mobilising major joints and stretching

The major joints are mobilised by taking each of them
through a normal range of movement (e.g. the shoulders Figure 8.6  Warm-up involving specific movements.

159
 Tidy’s physiotherapy

Key point

It is recommended that the patients should achieve a HR

within 20 bpm of the training HR or RPE of 10–11.

Cardiovascular conditioning
This component includes aerobic exercise training which
produces the beneficial physiological effects for the
healthy and cardiac population. Cardiovascular (CV)
training depends on the patients’ functional capacity and
his/her activity levels as determined in the assessment.
Functional capacity may be low for some sedentary
patients.
The exercise programme should be designed to produce A
a training effect which is achieved through varying the
frequency, duration, intensity and type/mode of exercise.
The principal goal is to improve the duration and effi-
ciency of exercise and then progress the intensity.
CV conditioning can be executed by continuous or
interval training approach.
• Continuous training is an aerobic activity performed at
a constant submaximal intensity which is prescribed
and monitored. For example, brisk walking, cycling,
stepping up and down on a step machine or bench,
and walking/running on the treadmill (Figure 8.7).
• Interval training consists of bouts of aerobic exercise
that are interspersed with periods of lower intensity
work. In the cardiac patients – particularly the B
elderly or those with low functional capacity – a
greater amount of work is achieved with the interval
Figure 8.7  Physiotherapist assisting the patient in setting the
training approach than with continuous training. It
intensity for exercise training on treadmill and cross trainer.
is also less daunting and encourages compliance.
Lower intensity exercises in the interval training are
also referred to as ‘active recovery’.
The CV conditioning period should be for 20–30
minutes. Circuit training is popular as it can be designed
with or without equipment. ‘Active recovery’ stations Key point
increase the endurance of specific muscle groups, for
example triceps, pectorals, trapezius. In supervised exercise programmes, interval circuit
Individualisation of the CV component is achieved by training is better suited to cardiac patients, at least in the
varying: initial period. The duration of activity is increased first
before increasing the intensity.
• the duration at CV station;
• the intensity;
• the period of rest between stations; down. Immediately after vigorous activity, venous return
• the overall duration of conditioning. will increase on lying down and will increase myocardial
workload. There is also an increased risk of orthostatic hypo-
Exercises performed in the recumbent position should be tension. Floor work when indicated (e.g. relaxation exercise
avoided during the CV conditioning phase because some and stretching) should be carried out after a cool-down
older adults may experience difficulty in getting up and period when the cardiovascular system has recovered.

160
 Cardiac rehabilitation Chapter 8

In this circuit, patients go round the circuit twice. The

instructor calls at 30 seconds.
The beginner achieves 10 minutes of work, patients at
intermediate level achieve 15 minutes of CV work and the
advanced-level patients achieve 20 minutes of CV work
(continuous training).

Figure 8.8  An example of a simple circuit set up with
cardiovascular and active recovery stations for a beginner in
phase III.
Cool-down
This consists of pulse-lowering exercises, large muscle
group stretching and joint mobilisation at a slower pace,
with movements of steadily reducing intensity. Its aim is
to return the cardio-respiratory system to near pre-exercise
levels within 10–15 minutes. It is essentially the reverse of
warm-up. A minimum period of ten minutes is recom-
mended for cool-down at the end of CV conditioning.
Following the sustained aerobic exercise training there
is an increased risk of venous pooling. This may also be
coupled with side effects of medication and can cause
hypotension. Cooling-down reduces the risk of hypoten-
sion, elevated HRs and arrhythmias.
Post-exercise supervision of 15–30 minutes is recom-
mended. In many programmes the education or relaxation
session follows the exercise, giving the opportunity for the
supervision of patients.

Table 8.8  An example of the circuit design

Progression
High intensity Active CV
This is achieved by increasing the duration, frequency or
(CV) stations recovery alternative intensity of training in order to maintain the training
stations stimulus. Ideally, serial exercise testing is used to modify
prescription. If this is not available then HRs and per-
1. Knee raises 2. Bicep curls Shuttle walk/
jog
ceived exertion at reference workloads can be compared
3. Treadmill 4. Lateral arm and the information used to increase any of the three vari-
(walking on raises ables or a combination of them. Progression over a long
incline) period is aimed towards a more continuous training
approach. Exercise progression will be highly variable
5. Step-ups 6. Upright rows
between individuals with CHD depending on the severity
7. Alternate 8. Forward press of disease, coexisting pathology, patient motivation and
side-taps with compliance.
theraband

9. Bike 10. Wall press Resistance training

CV = cardiovascular.
Class management
The control of the circuits needs to be carefully considered
(Figure 8.8; Table 8.8). One member of staff for five
patients is recommended.
• Beginner: 1 minute CV and 1 minute active recovery
(AR).
• Intermediate: 1 minute CV, 30 seconds AR and 30
seconds CV alternative.
• Advanced: 1 minute CV and 1 minute CV alternative.
Health-related physical fitness includes cardiovascular
(aerobic) fitness, muscle strength, endurance and flexibil-
ity, and body composition (lean–fat ratio). Muscle strength
is the ability of a muscle to produce a maximum force at
a given velocity of movement. Muscle endurance is the
ability of a muscle to perform repeated muscle contrac-
tions against a submaximal resistance. Resistance training
increases lean muscle mass and maintains basal metabolic
rate when combined with aerobic training, thus aiding in
weight management. By improving muscle strength and
balance it can reduce the risk of falling. Positive effects on
bone density are well known with resistance training.

161
 Tidy’s physiotherapy
Many activities of daily living, for example carrying
shopping bags and doing house-work, require upper body
strength. Cardiac rehabilitation professionals often come
across patients who are fearful of lifting or carrying out
resistance-based activities. Resistance training is associated
with an increase in arterial BP which increases myocardial
workload. Owing to these concerns, traditionally, aerobic
exercise training has been the main focus in the cardiac
rehabilitation programmes. However, recent research rec-
ommends resistance training as a part of a supervised
exercise programme in cardiac patients. Haemodynamic
and cardiovascular responses to resistance training are
similar in CHD patients and normal subjects. Because of
the increased diastolic pressure, myocardial perfusion may
be enhanced. It is now generally agreed that low- and
medium-risk cardiac patients can commence resistance
exercise after completion of an aerobic exercise programme
for 4–6 weeks : two sets of 8–10 exercises involving major
muscle groups performed a minimum of twice per week.
Currently in the UK, resistance training is not included in
cardiac rehabilitation programmes with high-risk patients.
Key point
Resistance training, principally planned to build up
muscular endurance, is associated with maintenance of
strength and can be performed safely by patients.
Contraindications to resistance training are:
• abnormal haemodynamic responses to exercise;
• ischaemic changes during graded exercise testing;
• poor left ventricular function;
• uncontrolled hypertension or arrhythmias;
• exercise capacity of less than six METs.
EXERCISE CONSIDERATIONS FOR
SPECIAL POPULATIONS
Heart failure
Heart failure is distinguished by the inability of the heart
to pump enough blood (and therefore deliver adequate
oxygen) to the metabolising tissues. A patient with heart
failure presents with symptoms of breathlessness and
fatigue at rest and swelling of the ankles. The New York
Heart Association (NYHA) has classified the stages of heart
failure based on the severity of symptoms (Table 8.9). The
prognosis for heart failure is poor, with 50% of patients
dying within four years and 50% of those diagnosed with
severe heart failure dying within a year.
Heart failure patients are classified as ‘high risk’ group
according to the AACVPR stratification criteria. Exercise
162
Table 8.9  The New York Heart Association
functional classification: The stages of heart failure
Class Patient symptoms
Class I (mild) No limitation of physical activity.
Ordinary physical activity does not
cause undue fatigue, palpitation or
dyspnoea (shortness of breath)
Class II (mild) Slight limitation of physical activity.
Comfortable at rest, but ordinary
physical activity results in fatigue,
palpitation or dyspnoea
Class III (moderate) Marked limitation of physical
activity. Comfortable at rest, but
less than ordinary activity causes
fatigue, palpitation or dyspnoea.
Class IV (severe) Unable to carry out any physical
activity without discomfort.
Symptoms of cardiac insufficiency
at rest. If any physical activity is
undertaken, discomfort is increased
Key point
Exercise-based cardiac rehabilitation intervention is safe
and effective in stable chronic heart failure patients.
Improvement of functional capacity, decreased symptoms
(‘Improved’ NYHA class) and quality of life is reported,
and are primarily a result of peripheral adaptations.
prescription and training for this group demands rigorous
assessment and monitoring. An appropriate safe environ-
ment and system needs to be in place to deliver exercise
training. Patients need to be stable – any change in the
clinical status may mean exercise is contraindicated. Based
on risk stratification, increased staff–patient ratio and
close monitoring of the symptoms of breathlessness (Borg
CR-10 scale may be desirable), HR, BP pre- and post-
exercise should be implemented. Interval training of 1–6
minutes of work/activity (40–60% functional capacity,
11–13 RPE) followed by rest is recommended.
Contraindications to exercise include:
• uncompensated heart failure;
• uncontrolled oedema;
• uncontrolled arrhythmias;
• symptoms at rest or with minimal exertion
(class IV);
• unstable angina;
• resting sinus tachycardia (>120 bpm);
• hypotension (SBP <90 mmhg);
• hypokalaemia (serum K <3.0 mEq/L).

Older adults
Many patients referred to cardiac rehabilitation are over
50 years of age. The changes associated with ageing need
to be accounted for when prescribing exercise. There is 1%
loss of VO2 max per year from the age of 25 years. Thus,
functional capacity can be reduced depending on activity
levels. Maximal HR declines with age. Lung elasticity and
chest wall expansion decrease with age. Bone density is
reduced by about 20% by the age of 65 years in women
and by 10–15% by the age of 70 years in men. Muscle
function declines by approximately 25% by the age of 65
years, as does joint flexibility and range of movement.
Lean body mass reduces and body fat increases.
Motor skills, balance, reaction times and motor coordi-
nation decline with age. One third of people over the age
of 65 years fall at least once a year. In addition, there may
be hearing problems. All these can contribute to anxiety
and diminished confidence to exercise. The exercise class
atmosphere should be social, welcoming, relaxed and
non-threatening. Patients need to feel comfortable.
Exercise prescription
Extended warm-up, and slow and controlled transition
between movements should be encouraged. Precautions
about extremes of weather should be taken.
• Frequency: 2–3 sessions per week.
• Intensity: lower end of prescription range (60–75%
HR max.), RPE Borg 11–14, more gradual progression.
• Type: endurance training of longer duration,
moderate intensity, resistance training to be
introduced later with 40–60% of 1 repetition
maximum (RM), maximum 8–10 repetitions, 1–3
sets, minimum of twice a week.
• Time: The conditioning period should be 20–30
minutes.
Hypertension
British Hypertension Society Guidelines (2004) advise
antihypertensive therapy at different thresholds as follows:
• individuals not at high risk of CHD/atherosclerotic
disease are classified to be hypertensive and treated
at BP of: 160/100 mmHg;
• individuals with CHD/other atherosclerotic disease
are classified to be hypertensive and treated at BP of:
140–149/90–99 mmHg;
• individuals with diabetes are classified to be
hypertensive and treated at BP of: ≥140/ ≥90 mmHg.
Exercise prescription
• Frequency: 3–5 times per week.
• Intensity: reduced to 50–75% maximum HR.
• Type: lower resistance/higher repetitions; avoid
Cardiac rehabilitation Chapter 8
over-gripping equipment; avoid valsalva manoeuvre
and isometric work.
• Time: increase duration at moderate intensity.
Exercise is contraindicated when SBP is >180 mmHg or
DBP is >100 mmHg. Antihypertensive medication may
lead to hypotension. Post-exercise extended active recovery
with constant feet movement is required to ensure venous
return.
Diabetes
Diabetes is a group of diseases marked by high levels of
blood glucose resulting from defects in insulin produc-
tion, insulin action or both.
Diabetes must be stabilised following events such as MI
and bypass graft surgery. Diabetic patients may not experi-
ence pain and can have silent ischaemia. Close supervision
during the session is required.
FITT principles apply for exercise prescription. Other
considerations:
• monitor blood sugar before and after exercise;
• insulin may need to be reduced on exercise days;
• exercise should be avoided when insulin is at its
peak effect; insulin uptake is increased if injection is
into an exercising limb;
• when new to exercise it is advisable to have other
people around;
• autonomic neuropathy may alter HR and BP
response;
• retinopathy;
• silent ischaemia – monitor for overexertion.
Peripheral vascular disease
Peripheral vascular disease (PVD) is also known as athero-
sclerosis, poor circulation or hardening of the arteries. It
presents with intermittent claudication and ischaemic
pain on exertion that diminishes with rest. It most com-
monly affects the legs (‘angina’ of the legs). In severe cases,
symptoms include cold, painful feet.
Patients need to be reassured as they suffer from a lack
of confidence to exercise beyond the point of pain.
Exercise prescription
• Frequency: increased frequency; short bouts of
exercise often better tolerated than continuous.
• Intensity: increased duration before intensity; use
peripheral vascular disease (PVD) scales of discomfort.
• Type: walking/weight-bearing.
• Time: daily exercise/graduated increase in duration.
Non-weight-bearing activities, for example cycling, can
be used to achieve prescribed cardiovascular dose and
improved compliance.
163
 Tidy’s physiotherapy
Obesity
Traditionally, a person has been considered to be obese if
they are more than 20% over their ideal weight. That ideal
weight must take into account the person’s height, age, sex
and build. Obesity has been more precisely defined by the
National Institutes of Health as a body mass index (BMI)
of 30 and above.
BMI is a measure of body fat based on height and weight
that applies to both adult men and women. It is weight
(kgs) divided by height (m2). As the BMI describes the
body weight relative to height, it correlates strongly (in
adults) with the total body fat content.
BMI categories:
• underweight: <18.5;
• normal weight: 18.5–24.9;
• overweight: 25–29.9;
• obesity: BMI of 30 or greater.
Obesity is also measured by measuring thickness of skin
folds. Central obesity is measured by waist–hip ratio
(>0.95 in males, >0.85 in females).
Exercise prescription
• Frequency: 3–5 times per week.
• Intensity: reduce to 50–75% HR maximum.
• Type: combine cardiovascular work and muscular
strength and endurance (MSE) work to reduce fat
weight and increase lean tissue; avoid high impact
work and stress on joints; provide alternatives and, if
necessary, avoid supine positions, which can restrict
breathing.
• Time: increase duration and frequency as able.
Osteoarthritis and rheumatoid
arthritis
Osteoarthritis (OA) is a degenerative arthritis caused by
wear and tear. It affects discrete joints. Rheumatoid arthri-
tis (RA) is a systemic illness characterised by inflammation
and can affect multiple joints.
Both conditions are marked by inflammation, pain and
restricted movement. In RA there may be periods of exa­
cerbation and remission. In advanced arthritis there may
be joint deformity.
Exercise prescription
• Frequency: 3–5 times per week (but rest during RA
exacerbations).
• Intensity: 60–75/80% HR maximum.
• Type: mobility/strength work for range of movement
and joint stability; low impact work to avoid stress
on joints; non-weight-bearing if limited by pain to
achieve cardiovascular prescription with minimal
discomfort; postural alignment.
• Time: 20–30 minutes.
164
Respiratory conditions
This may include asthma, chronic bronchitis and emphy-
sema. The presentation is different in each condition,
although the common symptoms are breathlessness and
increased work of breathing, with or without excessive
sputum production.
Exercise prescription
• Frequency: 3–5 times per week.
• Intensity: based on RPE; assessment on SWT.
• Type: endurance work; activities of daily living-based;
lower limb activity.
• Time: interval training of short duration; increased
duration/frequency as able.
EXERCISE PRESCRIPTION AND
DELIVERY ACROSS FOUR PHASES OF
CARDIAC REHABILITATION
Phase I: Inpatient period
Activities for cardiac patients following acute MI or CABG
do not typically exceed 2–3 METS in the early stages. These
include general mobility exercises and activities of daily
living, such as standing, walking, dressing and personal
hygiene. Before discharge, the patient is advised on the
progression of physical activity levels. Guidance on conva-
lescence activities over the first 3–4 weeks, written advice
on ‘do’s and don’t’ activities should be provided and,
usually, an incremental walking programme is also given
(Table 8.10).
Phase II: Immediate post-discharge
period
This period is usually between two and six weeks, and the
follow-up varies depending on local protocols. Often this
period is frightening for the patient and their family who
may feel isolated after the close supervision and support
in the hospital.
Although progression is individualised for each patient,
the following guide serves as a basis for prescription. The
patient should be advised on the signs and symptoms of
overexertion, chest pain management, timing of exercise
(40–50 minutes after a meal) and to avoid temperature
extremes.
Phase III: Supervised outpatient
programme, including structured
exercise
Structured exercise training during this phase is delivered
in either the hospital or the community. Access to
 Cardiac rehabilitation Chapter 8

Table 8.10  Incremental walking programme

Week Borg CR-10 scale Duration (min.) Distance (yards) Frequency (per day)

1 2–3 5 200 1–2

2 2–3 10 400–500 2

3 2–3 15 500–750 2

4 3 20 750–1250 1–2

5 3 25–30 1250–1750 1–2

6 3 30–40 1750–3000 1–2

Table 8.11  Structuring exercise sessions Table 8.12  Outcome measures assessment guideline

Staff–patient ratio Functional capacity Graded exercise test (SWT, CST)

Room size
Temperature 65–72°F Return to vocation Work modification
Humidity close to 65%
Smoking cessation Self-reported
Staff training
Emergency drills Managed BP Regular average BP recordings

Stress management HAD scale, self-reported rating

Quality of Life Measure of multiple domains

emergency facilities should be available. It lasts for 6–12 of quality of life
weeks in most centres. The sessions should be delivered
by professional staff with training in cardiology, exercise Lipids Lipid profile
prescription and emergency procedures. Consideration
Weight control Height, weight, BMI, waist–hip
should be given to the staff–patient ratio (one member
ratio
of staff per five patients is recommended in the UK
guidelines). BMI = body mass index; BP = blood pressure; CST = Chester step
The cardiac rehabilitation team delivering exercise ses- test; HAD = hospital anxiety and depression scale; SWT = shuttle
sions should all be trained in basic life support; preferably, walk test.
one member of the team delivering the exercise session (Adapted from American Association of Cardiovascular and
Pulmonary Rehabilitation 1995)
should be advanced life support trained. There should be
an access available for automated defibrillator (AED) and
the team trained to use it. All staff should have regular
practice with emergency drills. Local protocols for health Exclusion criteria for phase IV:
and safety should be followed at all times. The criteria for • unstable angina;
structuring exercise sessions is highlighted in Table 8.11. • testing SBP >180 mmHg, DBP >100 mmHg;
An outcome measures assessment guideline is shown in • significant drop in BP;
Table 8.12. • uncontrolled tachycardia;
• unstable or acute heart failure;
• febrile illness.
Phase IV: Long-term follow-up/
maintenance in primary care Discharge planning
Patients are transferred to phase IV when medically stable Following completion of phase III cardiac rehabilitation,
and psychologically adjusted. all patients’ individual long-term exercise plans are agreed
They should have reached their exercise goals. Patients and arrangements are made for transfer to phase IV. The
should demonstrate the ability to exercise safely based on patient is referred to the primary care service for monitor-
an individual exercise prescription and recognise warning ing of the risk factors. A patient may require further
signs and symptoms to take appropriate action (i.e. stop assessment, for example a patient experiencing residual
or reduce exercise level, take glyceryl trinitrate). ischaemia. In such cases, appropriate cardiology referral

165
 Tidy’s physiotherapy

Cardiac rehabilitation pathway including improvement in functional capacity and sec-

ondary prevention. Exercise consultation is a vital inter-
vention and should be available and incorporated
throughout all phases of cardiac rehabilitation. Exercise
Patient referred from ward/consultant/GP/other
intervention is a behavioural change and the rehabilita-
tion team should utilise counselling skills and deploy
strategies in order to promote long-term adherence to
Patient and family meet cardiac rehabilitation team for
exercise and physical activity.
comprehensive assessment following discharge
Physiotherapists have the knowledge, assessment skills
and clinical reasoning, combined with an evidence-based
Full pre-exercise assessment
approach, to deliver rehabilitation to patients with multi-
pathology problems. Thus, physiotherapists have a key
role in the physical activity component of all phases of
cardiac rehabilitation.
6–12-week exercise programme, twice weekly

Exit interview and reassessment/outcome measures

Weblinks

Phase IV referral www.cardiacrehabilitation.org.uk

Long-term helpline www.bcs.com
Long-term follow-up www.acpicr.com
Figure 8.9  The cardiac rehabilitation pathway. www.aacvpr.org
www.ic.nhs.uk
www.heartstats.org
and implications on exercise prescription are noted and www.bhf.org.uk
explained to the patient. All patients should be given
www.csp.org.uk
information about long-term helpline and local cardiac
www.dh.gov.uk
support groups (Figure 8.9).
www.sign.ac.uk
www.bhfactive.org.uk
CONCLUSION www.sahf.org.uk
www.ash.org.uk
Comprehensive cardiac rehabilitation is a cost-effective www.bhsoc.org
intervention for patients with cardiac disease. Exercise- www.diabetes.org.uk
based cardiac rehabilitation confers several benefits,

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BACPR (British Association for
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 Chapter
Physiotherapy in thoracic surgery
Anne Dyson and Kelly L. Youd
ANATOMY OF THE THORAX
The skeleton of the thorax is an osteocartilagenous frame-
work within which lie the principal organs of respiration,
the heart, major blood vessels, and the oesophagus. It is
conical in shape, narrow apically, broad at its base
and longer posteriorly. The bony structure consists of 12
thoracic vertebrae, 12 pairs of ribs and the sternum
(Figure 9.1).
The musculature of the thoracic cage is in two layers.
The outer layer consists of latissimus dorsi and trapezius,
the inner layer of the rhomboids and serratus anterior
muscles. Anteriorly, the chest wall is covered by pectoralis
major and minor. The intercostal muscles run obliquely
between the ribs. The diaphragm forms the lower border
of the thorax. It is convex upwards showing two cupolae,
the right being slightly higher than the left. It is made up
of muscle fibres peripherally and is tendinous centrally.
The lungs
The two lungs are basically very similar (Figure 9.2). The
right lung is made up of three lobes and the left of two
lobes. The lingular segment of the left lung corresponds
to the middle lobe on the right. Each lobe is divided into
segments.
The thoracic cage is lined by the pleura. There are two
layers, the parietal and visceral, which are continuous with
each other and enclose the pleural space. The parietal
pleura is the outer layer and lines the thoracic cavity. The
visceral pleura covers the surface of the lung, entering into
the fissures and covering the interlobar surfaces. The two
layers are lubricated by a thin layer of pleural fluid lying
within the pleural space, which, in healthy individuals,
contains no other structure.
9 
The oesophagus
The oesophagus is a muscular tube stretching from the
pharynx to the stomach. It is composed of mucosa and
circular and longitudinal muscle layers. The oesophagus
enters the stomach below the diaphragm at approximately
the level of the eleventh thoracic vertebra.
THORACIC SURGERY
Indications for surgery
Tumour
The most common reason for pulmonary and oesopha-
geal resection is a malignant tumour (carcinoma). A small
percentage of tumours can be benign.
Lung cancer is the most common cause of cancer in the
world and the second most common form in the UK,
second to breast cancer. In 2009 there were 41,500 new
cases of lung cancer diagnosed in the UK. The male to
female ratio is 4 : 3.
Oesophageal cancer is the ninth most common form of
cancer in the UK. There were 8,161 new cases diagnosed
in the UK in 2009 (Cancer Research UK).
Lung cancers are classified into two main categories
(NICE 2005):
• small-cell: 20% of all cases;
• non-small-cell: 80% of all cases including squamous
cell carcinoma, adenocarcinoma and large cell
carcinoma.
169
 Clavicle

Horizontal fissure

Sternum

Oblique fissure Lower border of lung

Lower border of pleura

Figure 9.1  Anatomy of the thorax. (Reproduced from Jacob 2001, with permission.)

1 1
2 Viewed
laterally
2
3
3
6
6 11
4
Lingula
5 12
8 8
9
9 10
Inferior 10 1 1 2 Inferior
lobe lobe
3
2
3
6

1 4 8 1
2 6 2 Upper lobe
Upper lobe 7
5 10
9
8 7 3
6
3 9 10 Viewed
6
medially
11
7
5 10
10 12
7 Lingula
Middle 9 Inferior Inferior
8
lobe lobe lobe 9 8

Figure 9.2  Anatomy of the lungs. Bronchopulmonary segments: 1 = apical, 2 = posterior, 3 = anterior, 4 = lateral, 5 = medial,
6 = apical basal, 7 = medial basal, 8 = anterior basal, 9 = lateral basal, 10 = posterior basal, 11 = superior, 12 = inferior.
(Reproduced from Palastanga et al. 2002, with permission.)
 Physiotherapy in thoracic surgery
Non-small-cell tumours are treated by resection if pos-
sible, if the tumour can be safely removed with clear
margins and if metastatic disease is not in evidence. Small-
cell cancer is virtually always widespread at diagnosis, so
surgery is usually not an option.
Malignant tumours of the oesophagus are generally
adenocarcinoma, especially in the lower end. They may
have arisen in the cardia of the stomach and spread proxi-
mally. In the middle and upper oesophagus, squamous
carcinomas predominate.
Benign tumours of the oesophagus and lungs are rare.
Pneumothorax
This is a collection of air in the pleural cavity. It usually
occurs spontaneously and is caused by rupture of the vis-
ceral pleura of an otherwise healthy lung. This is more
common in men than women and more usual in those
under 40 years of age.
Patients with chronic obstructive pulmonary disease
(COPD) can rupture a bulla resulting in a pneumothorax.
Other, much rarer, causes include tumour, abscess and
tuberculosis (TB). Traumatic pneumothoraces can occur
with blunt trauma to the chest wall, such as following a
car accident or heavy fall, or from a penetrating chest
wound, i.e. a stab or gunshot wound. Iatrogenic (medical
in origin) pneumothoraces can occur following intrave-
nous line insertion, after pacemaker insertion or in venti-
lated patients on high levels of positive end expiratory
pressure (PEEP).
Empyema
Empyema is a collection of pus in the pleural cavity.
The cause is commonly pneumonia, lung carcinoma or
abscess, bronchiectasis or, more rarely, TB. It can occur in
patients with septicaemia or osteomyelitis of the spine or
ribs. Most empyemas are located basally but they can
occur between two lobes.
Bronchiectasis
Bronchiectasis is a chronic lung condition in which abnor-
mal dilatation of the bronchi occurs associated with
obstruction and infection. Patients present with excessive
production of purulent secretions, which become chroni-
cally infected. Bronchiectasis is generally managed medi-
cally with a physiotherapy regime and antibiotics. In some
severe cases where the condition is localised to one area of
the lung, lobectomy can offer some relief of symptoms.
Oesophageal perforation
Trauma and perforation to the oesophagus may result
from the accidental swallowing of a foreign body (such as
a dental plate). The oesophagus can rupture in cases of
severe vomiting, especially if the patient tries to suppress
Chapter 9
the vomiting action. Iatrogenic perforation can occur fol-
lowing oesophagoscopy or surgery associated with the
pharynx.
Pre-operative investigations
Patients are assessed pre-operatively in order to establish
the nature of the lesion and whether they are fit for surgery.
The following investigations are commonly done.
Chest X-ray
A standard chest X-ray will be done on all patients to
establish pre-operative lung status.
Computerised tomography scan
In patients with cancer a computerised tomography (CT)
scan is done universally. The scan will locate the lesion
accurately and show if there is invasion into surrounding
structures, which determines operability. The presence
of metastases in distant organs is a contraindication to
surgery.
Positron emission tomography scan
In lung cancer, positron emission tomography (PET)
scans are sometimes used to look for cancer in the lymph
nodes in the centre of the chest or to show whether
the cancer has spread to other areas. This assists with
decision-making regarding adjuvant radiotherapy and
surgical intervention.
Bronchoscopy/oesophagoscopy
This will establish the site of the lesion and allow biopsy
or bronchial washings to be sent for histology. It can be
carried out under sedation or general anaesthesia.
Pulmonary function tests
Pulmonary function tests will help the surgeon decide
whether the patient can withstand lung resection. It will
also provide the anaesthetist with valuable information
to assess suitability for general anaesthesia.
Arterial blood gases
Arterial blood gases may be analysed routinely at some
hospitals or on high-risk patients, such as those with a
pre-existing lung condition.
Types of thoracic incision
Posterolateral thoracotomy
This incision is most commonly used for operations on
the lung (Figure 9.3). It is a curved incision that starts at
171
 Tidy’s physiotherapy

A B

Figure 9.3  The incision for a posterolateral thoracotomy.

the level of the third thoracic vertebra and follows the

vertebral border of the scapula and the line of the rib
extending forward to the anterior angle or costal margin.
C
An incision through the bed of the fifth or sixth rib is used
for pneumonectomy or lobectomy. Figure 9.4  Sternotomy. Common incisions. (a) Anterolateral
The muscles involved are the trapezius, latissimus dorsi, thoracotomy; (b) posterolateral thoracotomy; (c) median
rhomboids, serratus anterior and the corresponding sternotomy.
in­tercostal. A small piece of rib, approximately 1 cm,
may be removed to allow easier retraction and avoid a
painful fracture.

Anterolateral thoracotomy of the seventh rib and extends anteriorly over the costal
margin towards the umbilicus. The muscles involved are
This incision is used primarily for cardiac surgery but can
lattisimus dorsi, serratus anterior, the corresponding inter-
be used to perform pleurectomy.
costal and the abdominal muscles.
The incision starts at the level of the fifth costal cartilage.
If an oesophageal tumour is involving the middle third
At the sternal edge it follows the rib line below the breast
of the oesophagus, surgical access may be easier through
to the posterior axillary line. The muscles cut are pectoralis
a right thoracotomy and a separate abdominal incision. If
major and minor, serratus anterior and the corresponding
the tumour is in the upper third, then a cervical incision
intercostal (Figure 9.4).
will also be required.

Median sternotomy
This incision is used for lung volume reduction surgery
and bilateral pleurectomy. It is a vertical incision that
involves splitting the sternum.
The incision extends from just above the suprasternal
notch to a point about 3 cm below the xiphisternum. No
muscle is cut except the aponeuroses of pectoralis major
(see Figure 9.4).
Left thoraco-laparotomy
This incision is used for surgery on the lower oesophagus
and stomach. The thoracotomy incision follows the curve
Video-assisted thoracoscopic incisions
This technique aims to carry out conventional thoracic
operations through several very small (1–2 cm) incisions
as opposed to a posterolateral thoracotomy. Instead of the
surgeon seeing inside the patient directly, an endoscope
with video camera attachment is introduced into the chest
through one of the small incisions – the surgeon sees the
image produced on television monitors in theatre. Special-
ised instruments are inserted via the other incisions so the
operation can be completed. Advantages are reduced pain
and less impact on respiratory mechanics in the postop-
erative period, and much smaller scars.

172
 Physiotherapy in thoracic surgery Chapter 9

OPERATIONS ON THE LUNG

Sleeve resection
Figure 9.5 shows resection margins in lung surgery.
of right upper lobe

Pneumonectomy
Left
Extrapericardial pneumonectomy is carried out for pneumonectomy
tumours involving a main bronchus. The whole lung is
removed and the resulting cavity will fill with protein-rich
Right middle
fluid and fibrin over a period of weeks.
lobectomy
Lateral shift of the mediastinum, upward shift of the
diaphragm and reduction of the intercostal spacing on the
operated side reduce the size of the cavity.
Intrapericardial pneumonectomy is a more radical pro-
cedure involving the removal of part of the pericardium.
This is required when the tumour growth involves the
pericardium. Figure 9.5  Resection margins in lung surgery.

Lobectomy
This means removal of a complete lobe with its lobar Table 9.1  Complications of pulmonary surgery
bronchus. On the right side, two lobes can be removed
together – the upper and middle or middle and lower. Respiratory
Removal of the upper lobe on the right, known as a ‘sleeve • Sputum retention ± infection
resection’ can sometimes include a section of right main • Atelectasis/lobar collapse
bronchus. • Persistent air leak/pneumothorax
• Bronchopleural fistula (breakdown of the bronchus from
which the lung tissue has been resected, more likely to
Segmental resection occur following pneumonectomy and generally occurs
A segment of a lobe along with its segmental artery and about 8–10 days after surgery)
• Pleural effusion
bronchus are removed.
• Surgical emphysema
• Respiratory failure
Wedge resection Circulatory
• Haemorrhage
This is a small local resection of lung tissue. • Cardiac arrhythmia: atrial fibrillation will occur in
approximately 30% of lung resection patients
• Deep vein thrombosis
Lung volume-reduction surgery • Pulmonary embolus
Lung volume-reduction surgery is a procedure designed • Myocardial infarction
to improve respiratory function in patients with severe Wound
bullous emphysema. These patients present with hyperin- • Infection
flated lungs and a flattened diaphragm. By excising the • Chronic wound pain
bullous tissue and shaping the remaining lung, expansion • Failure to heal
Neurological
of the healthy lung and doming of the diaphragm can be
• Stroke
achieved. This will result in improved respiratory mechan-
• Recurrent laryngeal nerve (RLN) damage (the RLN
ics and symptomatic relief of dyspnoea (breathlessness).
supplies the vocal chords and trauma during surgery
Patients should undergo a period of pulmonary rehabilita-
will impair the patients’ ability to cough)
tion pre-operatively to maximise their respiratory function. • Phrenic nerve damage, resulting in paralysis of the
hemi-diaphragm
Complications of pulmonary surgery Loss of joint range
• Loss of shoulder range on operated side
The major complications of pulmonary surgery are listed
• Postural changes
in Table 9.1.

173
 Tidy’s physiotherapy
OPERATIONS ON THE PLEURA
Pleurectomy
Recurrent pneumothoraces will require surgical treatment.
In young patients this is usually on the second or third
occasion. In a small number of patients, bilateral pleurec-
tomy will be required. In the older patient presenting with
pneumothorax as a complication of COPD, surgery may
be required on the first occasion.
The procedure involves removing the parietal layer of
pleura from the chest wall in the area adjacent to the lung
injury. This leaves a raw area to which the lung becomes
adherent and thus unable to ‘collapse’ again. At the same
time any bullous lung tissue can be either ligated or
excised.
Decortication
Decortication is carried out following chronic empyema.
The procedure involves the removal of the thickened,
fibrous layer of visceral pleura from the surface of the
lung. This allows the lung to re-expand into the space
previously occupied by the empyema.
OPERATIONS ON THE OESOPHAGUS
Oesophageal resection
Tumours in the lower third of the oesophagus are resected
via a left thoracolaparotomy. The upper third of the
stomach is removed and the oesophagus from about
10 cm above the tumour margins. The remaining stomach
is passed through the hiatus of the diaphragm into the
posterior pleural cavity and a circular anastamosis created
between the distal oesophagus and tip of the gastric tube.
Tumours in the middle third are more easily dealt with
via a right thoracotomy and separate laparotomy. This is
known as an Ivor–Lewis procedure. The stomach is passed
into the right pleural cavity and the anastamosis con-
structed above the level of the aortic arch.
Tumours of the upper third will require resection of
virtually all the oesophagus and the anastamosis will be
made via an incision in the neck. The stomach is placed
as with the previous procedures.
Repair of oesophageal perforations
Oesophageal perforations are treated surgically by direct
repair. The site of the perforation will decide the nature of
the operation. Some perforations can be treated conserva-
tively and allow natural healing of the perforation without
operative intervention.
174
Complications of  
oesophageal surgery
All the complications of pulmonary surgery apply to
oesophageal operations. In addition, there may be chylo­
thorax, a pleural effusion resulting from the severing of
the thoracic chyle duct. The effusion when drained will
appear milky and on testing contain fat-staining globules.
Occasionally, surgical repair will be required, but usually
an intercostal drain (see below) will suffice until the
leak stops.
There may also be anastamosis breakdown, usually
owing to variable degree of gastric tubes necrosis.
INTERCOSTAL DRAINS
Key point
When thoracotomy has been performed and the pleura
opened, it is necessary to insert chest drains. These will
commonly be referred to as intercostal drains.
Most patients will require two intercostal drains, one sited
in the apex of the pleural cavity to drain air and allow the
lung to re-expand, and a second drain in the basal area to
drain postoperative bleeding. Patients undergoing pneu-
monectomy need only a single drain.
The drainage tubes are introduced through stab inci-
sions, in an intercostal space below the level of the thora-
cotomy and positioned within the chest before closure.
They are secured with a purse-string suture which will
allow a tight seal to be achieved while the drain is in situ
and on its removal. The apical drain is generally sited
anteriorly and the basal posteriorly. It is always wise to
check this in the operation notes.
The drainage tube passes from inside the pleural cavity
down to a bottle containing sterile water and attaches to
a tube that continues to below the level of the water
(Figure 9.6). Above the water level is a second tube that is
open to the atmosphere. This maintains atmospheric pres-
sure within the bottle. This is known as ‘an underwater
sealed drain’ and provides a simple, one-way valve allow-
ing air and blood to drain from the pleural cavity. Suction
can be applied to the short tube to reduce the pressure in
the bottle to below atmospheric and therefore encourage
the evacuation of air and blood.
On free drainage the fluid level in the tubing will rise
and fall. On inspiration the negative pressure in the thorax
pulls water up the tube and on expiration there is less
negative pressure in the thorax and the water level falls. If
the level ceases to swing then the lung is either fully
 Physiotherapy in thoracic surgery Chapter 9

From patient

To suction
or left open

Scale calibrated
in cc. Water level
in tube

Sterile
water

Under water therefore

drain from patient
has underwater seal
A

Suction tends
to pull water
level up.
Water level in tube
Figure 9.7  Underwater seal drainage in use.
pulled down

Amount and type of drainage

Expiration – less Inspiration –
negative pressure The amount of drainage is measured on a calibrated scale
negative pressure
in thorax, water in thorax pulls on the side of the bottle. Initially, this will be bloodstained
level in tube falls water up the tube but progress to serous fluid and then stop. Air drainage
can be seen as bubbles in the water, especially after cough-
ing. Persistent air leaks are the result of a hole in the lung
Water
Water tissue or at the resection site. Bubbling may continue for
level
level many days and an apical drain cannot be removed until
in tube
in tube this stops. The basal drain will be taken out 24–48 hours
postoperatively and the apical drain after 48–72 hours
unless there is continued drainage.
C

Figure 9.6  Effects of suction on water level: (a) the drainage

bottle; (b) the effect of suction on water level; (c) the effect PAIN CONTROL IN THORACIC
of the patient’s breathing.
SURGERY

For all the happiness man can gain is not in

expanded or the drain is blocked. There will be no swing
if the drain is connected to suction.
Drainage bottles must be kept below the level of inser-
tion to prevent the siphoning of fluid back into the pleural
cavity (Figure 9.7).
pleasure but rest from pain.
John Dryden (1631–1700)
Postoperative pain relief is not solely for the relief of an
unpleasant sensation. Disturbances of pulmonary func-
tion are common after any form of intrathoracic

175
 Tidy’s physiotherapy
operation. A decrease in functional residual capacity (FRC)
with minimal change in closing volume leads to atelectasis
(Sabanathan et al. 1990). Patients also experience an ina-
bility to cough effectively, thus becoming prone to sputum
retention leading to infection and arterial hypoxaemia (Ali
et al. 1974). Pain from the incision site and drains can be
severe for up to three days (Kaplan et al. 1975) and abnor-
mal patterns of breathing owing to pain will only worsen
these problems.
Good postoperative pain control is essential in order to
carry out effective physiotherapy. This can be delivered in
several ways: epidural anaesthesia, paravertebral block,
patient-controlled analgesia (PCA), transcutaneous nerve
stimulation (TENS) and oral analgesia are the most com-
monly used.
Epidural anaesthesia
An epidural provides delivery of a local anaesthetic agent,
such as bupivicaine, and an opiate, such as fentanyl,
directly into the small space just outside the dura mater
– the ‘epidural space’ (Figure 9.8). The local agent will
provide dermatomal relief over the incision site and the
opiate a more central effect.
Figure 9.8  An epidural used to provide pain relief after
surgery.
176
Epidurals can provide profound analgesia in consider-
ably smaller doses of opiate drug than if used systemically
(Chaney 1995). This will minimise the unwanted side
effect of respiratory depression commonly seen in opiate
use. Lui et al. (1995) demonstrated improved analgesia
with physiotherapy in thoracotomy patients using bupivic-
aine epidurals. An epidural will be inserted by an anaes-
thetist before the operation begins.
Paravertebral block
If it is not possible to insert an epidural, continuous
delivery of a local anaesthetic agent can be achieved
using a paravertebral catheter positioned in the paraverte-
bral groove. This can provide safe and effective pain
relief after thoracotomy (Inderbitzi et al. 1992). The
catheter will be sited by the surgeon prior to closure of
the chest.
Patient-controlled analgesia
PCA allows the administration of small doses of intrave-
nous opioids on demand by the patient. The patient must
be awake, co-operative and have had adequate instruction
pre-operatively on how to use the system. The dose deliv-
ered is dependent upon patient weight. A ‘lock-out’ inter-
val is set to allow time for the opiate to work; this also
prevents overdosing.
Transcutaneous nerve stimulation
TENS can be useful if it is initiated postoperatively to
relieve referred shoulder pain. The phrenic nerve supplies
the diaphragm and if irritated during surgery patients can
experience ipsilateral referred shoulder pain (Scawn et al.
2001). TENS can also be of benefit in patients with persist-
ent wound pain when an epidural or paravertebral has
been removed.
Oral analgesia
Epidurals, paravertebrals and PCAs will continue, on
average, for 72 hours, but analgesia will still be required
for many days. The pain experience is individual and
oral analgesia required will vary from patient to patient.
Simple analgesia, such as paracetamol or ibuprofen, may
be adequate, but some patients require stronger medica-
tion, such as dihydrocodeine or diclofenac. Oral medica-
tion can be prescribed on a regular or an ‘as required’
(p.r.n.) basis.
Most hospitals will have a specialist nurse for pain
control. The nurse will be very helpful in the care of
patients with severe pain that is difficult to control on
standard analgesia.
 Physiotherapy in thoracic surgery
THE PHYSIOTHERAPIST   Key point
AND THORACIC SURGERY
Key point
Chest physiotherapy has a place in the prevention, as
well as the treatment of postoperative pulmonary
complications.
Pre-operative care
The provision of pre-operative chest physiotherapy is not
routine, but it has been shown to be of benefit in high-
risk patients. For example, Nagasaki et al. (1982) demon-
strated that pre-operative physiotherapy for elderly patients
and those with COPD reduced postoperative pulmonary
morbidity.
Patients with pre-existing COPD are prone to increased
bronchial secretions (Massard and Wihlm 1998) and may
require chest clearance prior to surgery. Physiotherapy may
be requested by the patient’s medical team following
bronchoscopic findings (i.e. sputum retention).
The pre-operative care may vary from simple education
in postoperative techniques to more intensive chest
clearance.
Postoperative care
Postoperative complications commonly present as a
restrictive pattern with reduced inspiratory capacity,
reduced vital capacity (VC) and reduced FRC (Craig
1981). There are changes in defence mechanisms owing to
anaesthesia and reduced cough effort (Scuderi and Olsen
1989) that can lead to retention of secretions.
Postoperative physiotherapy aims to minimise the risk
of non-infectious and infectious pulmonary complica-
tions (Scuderi and Olsen 1989), the most common being
atelectasis and pneumonia. Other common problems
are loss of joint range in the shoulder on the incision
side and reduced mobility. Therefore, the main aims of
physiotherapy are:
• patient education;
• maximisation of lung volume;
Key point
Communication is of great importance in the successful
treatment of thoracic patients. The physiotherapist must
communicate with nursing and medical staff in order to
monitor the patient’s progress. Medical notes and chest
X-rays should be monitored on a daily basis. Effective
communication skills will result in improved patient
compliance and make treatment more effective.
Chapter 9
The provision of chest physiotherapy after thoracic
surgery is fairly routine in the UK, even though there has
been little specific research on the subject.
• prevention of sputum retention;
• sputum clearance;
• maintenance of shoulder range of movement;
• early mobilisation.
Patient assessment
The initial assessment of the patient leads to identifica-
tion of specific problems. Without an accurate assess-
ment an appropriate treatment plan cannot be initiated
(Pryor and Webber 1998). Re-assessment is then an
ongoing process to judge the effectiveness of treatment,
to identify new problems and to modify a treatment
plan. Table 9.2 lists what the initial patient assessment
should include.
Following assessment, the problems identified will
commonly include:
Table 9.2  The initial patient assessment notes
Database: obtained from medical notes
• Pre-operative information: pulmonary function tests and
arterial blood gases
• Surgical procedure and incision
• Concise relevant history of present condition
• Relevant past medical history including previous
surgery
• Social history
• Drug history, specific note of respiratory medicines, e.g.
inhalers
Subjective: information the patient tells you
• Ask open-ended questions: How do you feel?
• Ask about pain control: Can the person cough?
Objective: information based on examination of the
patient and tests carried out
• Cardiovascular status (CVS): blood pressure, heart rate
and rhythm
• Oxygen delivery system and FIV1
• Blood gases or O2 saturation
• Respiratory rate
• Chest X-ray
• Method of pain control
• Number and type of drains
• Auscultation
• Ability to cough
• Range of movement of shoulder on incision side
177
 Tidy’s physiotherapy

• reduced lung volume; Breathing control

• retention of secretions;
• increased work of breathing;
• poor breathing control/pattern;
3 – 4 thoracic expansions +/− inspiratory hold
• ineffective cough;
vibrations
• pain.

Breathing control
MODALITIES OF PHYSIOTHERAPY Return
to start
From the initial assessment and problem identification a 3 – 4 thoracic expansions +/− inspiratory hold
treatment plan can be formulated. vibrations
The amount of chest physiotherapy required will vary
from patient to patient. The patient’s individual require-
Breathing control

Key point
A particular treatment modality can be used to address
more than one problem. For example, the active cycle
of breathing technique (ACBT – see below) will be
effective in treating reduced lung volume and sputum
retention.
Forced expiratory technique
Figure 9.9  The active cycle of breathing technique (ACBT).
(Adapted from Pryor and Webber 1998.)
Patients should be encouraged to carry out at least two
full cycles every waking hour in order to maintain improve-
ments gained in lung function.

ments will primarily dictate how often and for how
long treatment is needed. Consultant preference and
hospital protocols may also influence this (Stiller and
Munday 1992).
Breathing exercises
The active cycle of breathing technique (ACBT) used in
sitting may be sufficient to maintain effective airway
clearance (Pryor and Webber 1998). ACBT consists of
cycles of breathing control and thoracic expansion exer-
cises followed by the forced expiratory technique (FET)
(see Figure 9.9). The thoracic expansion exercises can be
combined with inspiratory hold and vibrations. In patients
with reduced breath sounds, atelectasis and/or sputum
retention positioning in conjunction with ACBT may be
indicated.
The whole cycle should be repeated 2–3 times or until
the patient becomes non-productive. In early postopera-
tive patients, fatigue may be an issue and treatment should
be terminated at this point.
The thoracic expansions should be slow deep breaths in
through the nose and sigh out through the mouth. The
end-inspiratory hold can improve air flow to poorly ven-
tilated regions (Hough 2001); the breath hold should be
encouraged at the height of the inspiratory effort for 2–3
seconds.
Forced expiration
The FET is used to help in the clearance of excess bronchial
secretions.
The forced expiratory technique
The technique was defined by Webber and Pryor in 1979.
FET is one or two forced expirations from mid-lung to
low-lung volumes (Partridge et al. 1989).
An effective FET should sound like a forced sigh. It is
dependent on:
• mouth open;
• glottis open;
• abdominal wall contracted;
• chest wall contracted.
Crackles may be heard if secretions are present.
FET performed to low lung volumes will aid removal
of secretions peripherally situated. High lung volumes
will clear secretions from proximal airways (Pryor and
Webber 1998).
Supported cough
A cough is created by forced expiration against a closed
glottis. This causes a rise in intrathoracic pressure. As the

178
 Physiotherapy in thoracic surgery
Figure 9.10  Coughing: patient supporting wound.
glottis opens there is rapid, outward airflow and shearing
of secretions from the airway walls.
Improved coughing and FET can be achieved if the
wound is supported (Figure 9.10). This can be done by
the physiotherapist during treatment sessions or by the
patient. The arm on the unoperated side is placed across
the front of the thorax and over the incision and drain
sites. Firm overpressure is applied during coughing/FET. A
towel, folded lengthways, passed around the back of the
patient and pulled across the front of the thorax can also
be useful to support coughing.
Positioning
Key point
The major function of positioning postoperatively is to
improve FRC. A good sitting position either in or out of
bed, as opposed to slumped in the bed, can achieve this
(Jenkins et al. 1988).
There are recognised positions for segmental drainage
(Thoracic Society 1950) and these may be utilised if
there is a segmental or lobar-specific problem. It is much
more likely, however, that modified positions only will
be required, especially in view of the changed anatomy of
the area.
Positioning can also be used to improve gas exchange.
Improvement in oxygenation can be achieved in side-
lying with the affected lung uppermost; the ventilation/
perfusion match is improved, resulting in increased oxygen
uptake (Winslow et al. 1990).
Pneumonectomy patients should not be positioned on
their unoperated side. This can result in bronchopleural
Chapter 9
fistula owing to space fluid washing over the bronchial
stump. Patients undergoing intrapericardial pneumonec-
tomy should be treated in sitting for the first four days
unless advised otherwise by the medical team.
Early mobilisation
Mobilisation should commence as soon as is safely
possible as functional residual capacity is maximally
improved in standing (Jenkins et al. 1988). Dull and Dull
(1983) proposed that early mobilisation in uncompli-
cated patients could render breathing exercises unneces-
sary. Patients must be cardiovascularly stable and not
requiring high concentrations of oxygen before mobilisa-
tion can begin. If intercostal drains are on suction, mobil-
ity will be restricted to standing and spot-marching at
the bedside. Some anaesthetic departments restrict mobil-
ity when an epidural is in situ owing to the risk of pro-
found hypotension on mobilising. Hospital protocols
should be noted.
Shoulder exercises
The shoulder on the operated side should be checked
for range of movement. The patient should practise
elevation and abduction of the shoulder at least three
times a day. Auto-assisted exercises may be necessary to
begin with. Any limitation of range should be more for-
mally assessed and treated.
Adjuncts to physiotherapy
Physiotherapy is a ‘hands on’ practice. There are several
adjuncts that can be used to augment the basic breathing
exercise regimen.
Incentive spirometer
Incentive spirometry is a feedback system to encourage
patients to take a deep breath and produce a sustained
maximal inspiration in order to open atelectatic areas of
lung (Su et al. 1991) (Figures 9.11 and 9.12). It is cheap
to provide, non-invasive and, when taught well, needs
minimal supervision.
Bastin et al. (1997) deduced that deterioration in incen-
tive spirometer performance could be used as a warning
of pulmonary deterioration.
Mini-tracheostomy
Sputum retention is a frequent complication in patients
recovering from thoracic surgery (Busch et al. 1994). It
can be a result of sputum tenacity or a weak ineffective
cough. Mini-tracheostomy can be an invaluable tool in
179
 Tidy’s physiotherapy
Figure 9.11  The incentive spirometer.
Figure 9.12  The incentive spirometer in use.
the postoperative patient to aid removal of secretions in
conjunction with a physiotherapy regimen.
Quidaciolu et al. (1994) concluded that mini-
tracheostomy was safe and effective in reducing respira-
tory morbidity in high-risk patients following pulmonary
surgery.
180
Heated humidification
Pulmonary secretions can become tenacious following
surgery. This may be a result of anaesthesia, infection or
dehydration – especially in oesophageal patients who are
‘nil by mouth’. Improving humidification to the airways
by heating the oxygen/air delivery can help in mucus
clearance.
Continuous positive airways
pressure
Patients with poor arterial blood gases and reduced
lung volume can be supported by the use of continuous
positive airways pressure (CPAP). It can be used continu-
ously or intermittently. When used continuously it must
be humidified.
CPAP is effective in improving FRC and arterial oxygen
in patients with acute respiratory failure. It can also reduce
the work of breathing (Keilty and Bott 1992). Care must
be taken in thoracic patients because of the anastamosis
and medical opinion should be sought.
Intermittent positive pressure
breathing
There is little literature to support the use of intermittent
positive pressure breathing (IPPB), but with good teaching
and in the right patient it can be effective. It is of particular
use in patients who have loss of lung volume and are
tiring. It works to improve lung volume and reduces the
work of breathing.
Extreme care must be used when considering IPPB
on lung resection patients as the anastamosis may
be vulnerable to positive pressure. The physiotherapist
should discuss the use of IPPB with the patient’s
medical team.
DISCHARGE
Patients will reach discharge from treatment at varying
points in their recovery. A low-risk patient with no post-
operative complications may only need 3–4 days of physi-
otherapy. High-risk patients and those experiencing
pulmonary complications will need considerably more.
FRC and VC can be regained even in lung resection
patients. The time for full recovery of FRC is about two
weeks and for VC it can be in excess of three weeks (Craig
1981). Once discharged, the patient should be advised to
continue with regular breathing exercises and gradually
increase their mobility.

ACKNOWLEDGEMENTS
The authors and editor would like to thank Mr Richard Page (consultant thoracic surgeon), Jenny Chauveau (acute
pain nurse specialist), Mary Kilcoyne (physiotherapist) and all physiotherapy staff at Liverpool Heart and Chest
Hospital NHS Foundation Trust and Jo Sharp (lecturer) at the University of Liverpool.
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181
 Chapter
Changing relationships for promoting health
Sally French and John Swain
INTRODUCTION
Our focus for this chapter is ‘changing relationships’. The
chapter is divided into three sections. The first, ‘between
people’, focusses on the dynamics of relationships within
therapy practice, at the interpersonal level, and also broad-
ens the discussion to the group level, looking at questions
of culture. The second section, ‘context of relationships’,
considers the social context of relationships, particularly
inequalities in health and healthcare, and the various ide-
ologies and viewpoints that prevail in therapy practice.
Finally, in ‘changing relationships’, we look towards the
possibilities for changing the dynamics of relationships,
focussing first on the notion of partnership and then on
health promotion itself. We both work in the field of dis-
ability studies and will draw examples from our own work
and that of others in this field. Thus, the chapter is particu-
larly orientated towards disability and therapy with disa-
bled people. The processes we are examining, however, are
general and, overall, we hope to demonstrate the inter-
relationships between the interpersonal, personal, cultural
and societal in the dynamics of changing relationships to
improve and promote health.
BETWEEN PEOPLE
Communication
The provision of physiotherapy can be thought of as a
form of communication and the whole process as one of
communication between the client and the physiothera-
pist, between the physiotherapist and colleagues (includ-
ing other physiotherapists, doctors, etc.) and between the
physiotherapist and members of the client’s family. The
10 
Labelling people
Various terms are used to refer to disabled people in
relation to services. All are being challenged by disabled
people themselves.
• Patient: this term clearly labels people in medical
terms and is derived from ‘pati’, meaning ‘suffer’.
• Client: this refers to a person using the services of a
professional (lawyer, architect, medical practitioner,
etc.). In recent times, the term ‘customer’ has also
been used.
• Service user: this is, perhaps, the most neutral term,
although it still labels people according to their
relationship with services.
purpose of this section, then, is to examine interpersonal
communication in the particular context of physiotherapy
practice.
There are a number of important aspects to a social
model of communication. Interpersonal communication
is viewed as an interplay between people in which partici-
pants are both active agents, affecting the interplay, and
reactive agents, affected by the interplay. There is no simple
one-to-one correspondence between acts of communica-
tion and the meaning expressed. The context is all impor-
tant. Silence, for instance, can ‘say’ more than words, but
has no meaning outside the particular interpersonal and
social context. It could be taken to mean the person is
experiencing boredom, fear, respect, deep mutual under-
standing, passion, hatred – the list is potentially endless.
Even signals that usually have a well defined meaning,
such as raising the hand to signal ‘stop’, depend on the
context of the two-way flow. If accompanied by a smile,
183
 Tidy’s physiotherapy

This takes us into clients’ experiences of services, concen-

MODELS OF COMMUNICATION
Linear models
Linear models of communication seem to accord with
common sense, as communication is viewed as a process
of sending and receiving messages. A popular
communication model that is used in the literature is as
follows.
1. Sender (self).
2. Encoder (converting thought into message).
3. Channel (verbal, non-verbal, both verbal and
non-verbal).
4. Decoder (interpretation of message).
5. Receiver (other/others).
(Rungapadiachy 1999:195)
Social models
A social view of communication posits a dynamic model
in the sense that communication is seen as a transaction
constructed between people.
Social models concentrate more on the
communication process itself, rather than the notion of
message sending (Pearce 1994). From this perspective,
improving communication is not a simple matter of
improving physiotherapists’ skills of expressing and
listening to information. Communication is ‘meaning-
making’ rather than ‘information processing’ and
meanings are constructed between people.
Communication is both based on and generates our
perceptions, descriptions and understandings of the
world or, more specifically, physiotherapy.
trating on barriers to communication, recognising that any
analysis of barriers to communication needs to identify
the complexities of the communication process itself
and the diversity of clients’ experiences (Figure 10.1). Such
an analysis also needs to recognise the inequality of
professional–client relationships. Professional dominance
can be seen in assessment procedures where, for example,
the professional’s observations are viewed as ‘objective’
whereas the patient’s perceptions are viewed as ‘subjec-
tive’, and where pseudo-scientific language serves to
mystify and confuse service users (French 1993). Because
of the specialisation of the various professional groups,
definitions of need tend to be narrow, their scope being
dictated by specialised knowledge and interests. The needs
of disabled people, however, tend to be multifaceted. As
Marsh and Fisher (1992: 50) point out:
If the process of assessment becomes one of
professional discovery of ‘need’, rather than a

for instance, the raising of the hand could be meant as,

and understood to be, a joke. Furthermore, this model
is holistic. Meaning-making is constituted through the
organisation and system of a conversation with the whole
being greater than the sum of the parts. Physiotherapy–
client communication is not just a means for undertaking
physiotherapy practice: the participants are creating physi-
otherapy practice through their communication.

Barriers to communication from the viewpoint

of clients

• Inequality of professional–patient relationships.

• Attitudinal barriers.
• Barriers to access to services.
• Barriers to access to information.
• Lack of concern on the part of professionals with
emotional issues. Figure 10.1  Barriers to communication, a means of
• Lack of disabled professionals. oppressing women, or a symbol of personal, cultural and
religious identity?

184
 Changing relationships for promoting health
negotiation of problems, then users tend to feel
hemmed in by the definitions used to describe
their circumstances and trapped by the choices
they are faced with.
Attitudinal barriers are commonly referred to by disabled
clients. Boazman (1999: 18–19), for instance, had mixed
responses from health professionals when she became
aphasic following a brain hemorrhage:
Their responses towards me varied greatly, some
showed great compassion, while others showed
complete indifference. I had no way of
communicating the fact that I was a bright,
intelligent, whole human being. That is what
hurt the most.
Similar mixed experiences were reported by people with
aphasia interviewed by Parr and Byng (1998: 74). One
person, talking of doctors, said:
… when you can’t communicate they treat you
like a kid and that is just so frustrating … A
handful of doctors were just awful. You just
wanted to say, ‘Do you know what this is like?’
Pound and Hewitt (2004) write of the equation of com-
munication disability with ‘having nothing to say’ and
‘being stupid’ which, they believe, illustrates the ‘Does he
take sugar?’ syndrome (Figure 10.2). In another, small-
scale study involving people with speech impairments, it
was found that most difficulties were encountered within
medical services. Doctors’ and dentists’ receptionists were
singled out for particular criticism (Knight et al. 2002: 19).
Mary, one participant, recalled:
My most embarrassing incidents have been with
my doctor’s and dentist’s receptionists. I have
had more trouble with them than with any
other group. They were impatient and rude
Figure 10.2  Does she take sugar?
Chapter 10
when I tried to make appointments, and would
talk to my carer when I was trying to ask
questions.
Another participant described his encounters with hos-
pital consultants:
They have excluded my carer from any
discussion despite me indicating that I preferred
to have my carer lip-read to avoid having to use
my oesophageal voice.
Another common complaint of the research partici-
pants in this study was the means of access to services that
generally depended on the telephone.
People with speech and language impairments are often
compelled to wait long periods of time for the communi-
cation equipment they need. A survey conducted by Scope
(Ford 2000: 29) found that nearly a fifth of people waited
for more than a year. Professionals may also have control
of when the equipment can be used. One of the research
participants said:
Physiotherapists at school have recommended
the Delta Talker be removed from situ during
travelling because of possible safety problems.
They also used to request removal of the talker
at meal times.
Deaf people have complained about the insistence of
professionals that they use speech rather than sign lan-
guage. A deaf person interviewed by Corker (1996: 92)
states:
I hated learning speech – hated it – I felt so
stupid having to repeat the s,s,s ….. I was
asking myself ‘Why do I have to keep going over
and over it, I don’t understand what it all
means’ ….. It was just so stupid, a waste of
time when I could have been learning more
important things.
In interviews conducted by French (2004a: 99), two
participants spoke of their experiences of occupational
therapy:
I’ve often thought about OTs [occupational
therapists] in rehab, if only they could think
about the context from which their patients
came. I was received as head of department
of a girls’ comprehensive school, head of
physical education, and this OT said to me,
‘Now you’ve really got to learn to type because
that’s what you’ll be doing.’ She negated the
whole context of my professional life – I was
just a patient.
185
 Tidy’s physiotherapy
It was a case of being treated like a patient. I
felt like my feelings were being ignored, that
they were just going through a routine and they
would give me exercises to do which I couldn’t
understand the purpose of because they didn’t
explain. I had enough speech to ask, but I
didn’t ask, because I didn’t have the confidence
to ask.
Information can also be given in an insensitive way as
Joan (interviewed by French et al. (1997: 37)) explained:
When I came back for the negatives, oh it was
terrible. He lifted them up to the light and he
said to the nurse ‘Macula degeneration in both
eyes, sign a BDS form’ or whatever it is. Then
he turned to me and he said ‘There’s nothing
we can do about it …… You’ll always be able
to see sideways but you’ve got no central vision’
…. So I came home feeling very upset about it.
Being unable to access information is a problem faced
in all areas of life by visually impaired people, with poten-
tially hazardous consequences of unreadable notices and
loss of privacy when documents are unreadable by the
intended recipient. Vale (2001) reports that appointment
letters continue to be sent out in standard-size print, even
by many hospital eye clinics, and only one third of
National Health Service (NHS) hospitals offer general
patient information in large print.
It is important to recognise that social divisions, for
example gender, age and ethnicity, intersect disability and
also produce communication barriers in some instances.
Summarising the evidence from several studies of the
experiences of disabled people from ethnic minority com-
munities, Butt and Mirza (1996: 94) state:
The fact that major surveys of the experience of
disability persist in hardly mentioning the
experience of black disabled people should not
deter us from appreciating the messages that
emerge from existing work. Racism, sexism and
disablism intermingle to amplify the need for
supportive social care. However these same
factors sometimes mean that black disabled
people and their carers get a less than adequate
service.
In their study of young black disabled people’s experi-
ences and views, Bignall and Butt (2004: 49) conclude:
Our interviews revealed that most of these
young people did not have the relevant
information to help them achieve independence.
186
Hardly any knew of new provisions, such as
Direct Payments, which would help with
independent living. Most people did not know
where to get help or information they wanted,
for example, to move into their own place or go
to university.
Begum (1996) takes institutionalised discrimination as
her basis for analysing difficulties in the relationship
between disabled women and their general practitioners
(GPs). She explored physical, communication and atti-
tudinal barriers, and found that they deny opportunities
to women with impairments and can impede access to
the services they require. Disabled women, for instance,
often find that information is withheld from them.
One of her respondents explained that she had not been
told that multiple sclerosis had been diagnosed, yet her
husband had been told two years before she was
informed. It also seems that the flow of information
from disabled people to GPs is liable to distortion and
failure. This is, at least in part, owing to GPs’ responses
to impairment. One respondent in the research said:
‘Sometimes I find that a GP – particularly one who is
only here for a short time and fairly new – is more
interested in my sight problem, or my child’s sight
problem, than in what I’ve come to ask about’ (Begum
1996: 83–84). Age can also be a factor that distorts com-
munication. Olwen (interviewed by French et  al. (1997;
35)) talking about the attitude of professionals to her
loss of sight said: ‘Even though I’m older they were “…at
your age what can you expect?”. You know they talk to
you like that.’
Disabled professionals stand in an interesting position
in an analysis of communication between professionals
and disabled people. It can both be argued that the barri-
ers to communication have discriminated against disabled
people wishing to be service providers and also that the
acceptance of more disabled people into the professions
would be a significant factor in developing inclusive
communication. A visually impaired physiotherapist
interviewed by French (2001: 140) spoke of poor com-
munication with her colleagues:
I’m a registered blind person but they haven’t
got a clue … If I stay in one building I’m fine,
it’s only when I go over to G … that I get really
lost … and one of the physios says, ‘So you’re
not talking today!’ because I’ve walked right
passed them … and I’ve worked with them for
years; oh dear … I just say ‘I didn’t see you’ but
they don’t seem to learn.
Other health professionals have spoken of the advan-
tages they have when communicating with ill and disabled
clients (French 1988: 178). A disabled doctor explains:
 Changing relationships for promoting health
Very many people have told me they can talk to
me because I know what it feels like to have an
illness. Once you get over that hump of being
accepted for training then you can use your
disability.
Cultural differences
Definition
Culture is a general term for the symbolic and learned
aspects of human society. A set of basic assumptions
– shared solutions to universal problems of external
adaptation (how to survive) and internal integration (how
to stay together) – which have evolved over time and are
handed down from one generation to the next.
Here, our focus is on inequality of power, locating culture
within its socioeconomic, political and historical context.
One layer of power is provided by the wider social relation-
ships in which everyone in health and social care – service
users and service providers – are embedded. In this broader
social context, there are significant and constantly chang-
ing differences in power between people belonging to dif-
ferent groups embedded in different cultures. Some groups
have greater power, resources, status and better health.
Others can face discrimination – including members of
ethnic minority groups, disabled and older people – in a
variety of areas, including access to required services.
Definition
Institutionalised discrimination is unfair or unequal
treatment of individuals or groups that is built into
institutional organisations and can result from the
majority simply adhering unthinkingly to the existing
organisational rules or social norms.
Language, in terms of cultural issues, is often seen as the
main barrier to effective service provision. It is, therefore,
assumed that an adequate supply of leaflets in appro­
priate languages and interpreters will solve the problem.
However, communication consists of more than language
skills and literacy. Research by Banton and Hirsch (2000:
32) suggests that even among UK-born English-speaking
Asians, there is considerable lack of knowledge of what
services are on offer. They state:
Communication problems are identified in all
work in this area. Such problems are partly to
do with language differences, but also arise from
the separate lives led by different ethnic groups
Chapter 10
in our society and the consequent unlikely
coincidence of communications about services
arising through informal contacts.
Perhaps the most consistent recommendation from
research has been the necessity for the direct involvement
of disabled clients, including black disabled clients, in the
planning of services (Butt and Box 1997). Again, this
needs to be understood within the context of multiple
discrimination. Concluding their study with young deaf
Asian people and their families, Jones et al. (2001: 68)
state:
… identities are not closely tied to single
issues and young people and their families
simultaneously held on to different identity
claims. To this extent, it is not a question of
forsaking one claim for another and choosing,
for instance, ‘deafness’ over ‘ethnicity’, but to
negotiate the space to be deaf and other things
as well. It is only through addressing these
tensions that services will adequately respond to
the needs of Asian deaf people and their
families.
In 1991, Hill drew attention to the extremes of oppres-
sion faced by black disabled people. She stated that the
cumulative effect of discrimination is such that black disa-
bled people are ‘the most socially, economically and edu-
cationally deprived and oppressed members of society’
(1991: 6).
Studies of the families of Asian people with learning
difficulties also provide evidence of high levels of poverty,
with 69% of families having no full-time wage earner and
half of the families being on income support (Nadirshaw
1997). Significant language barriers were found in the
same study with 95% of carers being born outside the UK
and only a minority able to speak or write English.
There are dangers, however, in such statistics. Firstly,
they can feed presumptions and stereotyping which belie
diversity. In her study of Asian parents, for instance, Shah
found that ‘the majority of parents had a good command
of English and, for some, English was their first language’
(1998: 186). She also cites language barriers as an example
of preconceived notions of discrimination experienced
by Asian families. Secondly, there is a danger of over-
simplifying language barriers. Language engages us in
freedom of expression, release of emotion, developing cul-
tural identity and sharing values. A common language,
therefore, is no guarantee of shared understanding. At the
attitudinal level of institutional discrimination, there is a
lack of understanding among the majority population
concerning the life style, social customs and religious prac-
tices of people from ethnic minority groups (Atkin et al.
2004). Discrimination has sometimes been denied and
187
 Tidy’s physiotherapy
rationalised through myths that, for instance, black fami-
lies prefer ‘to look after their own’.
Comparable analyses of the experiences of the interac-
tion of other social divisions, for example disabled and
old, disabled and female, disabled and gay or lesbian, and
disabled and working-class, indicate that there are paral-
lels. For instance, in the most extensive research into the
views and experiences of disabled lesbians and bisexual
women, there was evidence that they felt marginalised by
lesbian and gay groups: ‘…many disabled lesbian and
bisexual women have experienced alienation rather than
nurturing and support from the lesbian and gay commu-
nity’ (Gillespie-Sells et al. 1998: 57).
Another, more recent, addition to the list of groups with
fragmented identities whose interests are not fully taken
into account by single issue movements is disabled refu-
gees and asylum seekers who ‘constitute one of the most
disadvantaged groups within our society’ (Roberts 2000:
945). Disabled refugees and asylum seekers are ‘lost in the
system’ because both ‘…the disability movement and
the refugee community focus their attention … on issues
affecting the majority of their populations and fail to
engage adequately with issues which affect a small minor-
ity’ (Roberts 2000: 944).
CONTEXT OF RELATIONSHIPS
Inequalities in health
To the busy physiotherapist with many patients to treat
and assess, it may seem that illness, impairment and acci-
dents ‘just happen’ and that whether somebody has a
fractured hip, a chest infection or a stroke, is largely a
matter of chance. All the major research reports over the
years, however, demonstrate that mortality, morbidity and
life expectancy are strongly correlated with socioeconomic
class with those in the lower social classes being at a con-
siderable disadvantage (Townsend and Davidson 1982;
Whitehead 1988; House of Commons Health Committee
2009). Although the UK has become healthier and wealth-
ier over the years, health inequalities persist; in fact, the
gap between the richest and poorest sectors of society has
widened (Asthana and Halliday 2006; Wiles 2008).
Definition
Socioeconomic status is the structural position in society
of an individual or a group compared with other
individuals and groups. It is a central term in the social
sciences and a subject of considerable controversy. In
official statistics, people are generally classified on the
basic of their occupation and income.
188
Certain groups within society such as old people, people
from ethnic minorities and disabled people are also dis-
advantaged partly because of their over-representation in
the lower socio-economic groups (Power and Kuh 2006).
There is also something of a north/south divide with
people in the north of the UK having more ill health than
those in the south, although there is much variation
(Naidoo and Wills 2008).
This section of the chapter will examine the meaning of
health inequalities. In order to do this it is necessary to
consider what is meant by ‘health’.
Definition
Definitions of health differ between individuals, cultural
groups and social classes. One view is that health is the
absence of disease or illness. From a broader perspective,
health includes the physical, psychological, behavioural,
social and spiritual aspects of a state of well-being and
recognises the importance to individuals of realising
aspirations and needs.
In 1946 the World Health Organization (WHO) defined
health as, ‘A state of complete physical, psychological and
social well being and not merely the absence of disease or
infirmity’ (WHO 1946, cited in Ewles and Simnett (2003:
6)). Although this definition moved the concept of health
away from a biological and towards a more holistic under-
standing, it was criticised for being idealistic and unreal-
istic, and for failing to recognise that people define their
health in a variety of ways based on their knowledge,
values and expectations, and whether or not they can fulfil
roles of importance to them (Jones 2000a). In 1984, the
WHO (WHO 1984 cited in Ewles and Simnett (2003:7))
redefined health as:
… the extent to which an individual or group is
able, on the one hand, to realise aspirations and
satisfy needs; and, on the other hand, to change
or cope with the environment. Health is,
therefore, seen as a resource for everyday life,
not the objective of living; it is a positive
concept emphasising social and personal
resources as well as physical capacities.
This holistic definition of health is reflected in the book
Meeting the Health Needs of People Who Have a Learning
Disability (Thompson and Pickering 2001) which contains
chapters on self-concept, meaningful occupation and life
transitions. It can be argued that unless we feel good about
ourselves and have meaning in our lives, such as going to
work, raising a family, learning new skills, visiting friends,
helping others or pursuing hobbies and interests, we
 Changing relationships for promoting health
cannot be fully healthy. Having a sense of control over our
lives and being connected to the people around us are also
important for health and well-being (Naidoo and Wills
2008; Wiles 2008).
There are many influences on all aspects of our health.
Dahlgren and Whitehead (1995) depict these as layers
piled on top of each other. At the bottom of the pile are
biological factors over which we have limited, or no,
control. These include our sex and age, and the genes we
inherit from our parents. Many diseases become more
common as we grow older (e.g. cancer and cardiovascular
disease), some diseases are specific to men or women (e.g.
prostate and ovarian cancer), while others are genetic or
congenital in origin (e.g. cystic fibrosis and congenital
heart disease). When the NHS was established in 1948 it
concentrated on this biological layer. It was hoped that
improvements in health would eliminate health inequali-
ties but although the overall health of the population has
gradually improved (mainly through improved living con-
ditions) the gap between the social classes has widened
(Asthana and Halliday 2006; Wiles 2008).
The second layer focusses on our personal behaviour.
This includes whether or not we smoke cigarettes or eat
too much, the amount of exercise we take and how well
we attend to our health needs in the broadest sense. Most
policy initiatives from government have focussed on this
layer, where attempts have been made to change peoples’
behaviour in order to improve their health, for example
anti-smoking campaigns (Jones 2000b; DH 2004; Wiles
2008). This emphasis on personal behaviour has, however,
been criticised. Asthana and Halliday state that ‘…the
government’s strategy suggests an implicit assumption
that health inequalities can be reduced without changing
overall levels of inequality’ (2006: 98). There is also a
denial of the ways in which the social setting affects our
behaviour and reduces our control.
The next layer concerns social and community influ-
ences. The people around us, including family members,
neighbours, colleagues and friends, can influence our
health by giving meaning to our lives and providing assist-
ance and support in times of illness, difficulty and stress.
Conversely, these people can have a detrimental effect on
our health by neglect, abuse or failing to take account of
our needs. Organisations such as the church and self-help
groups may also be important (Asthana and Halliday
2006). Berkman and Melchior (2004) point out that social
networks provide opportunities for support, access, social
engagement and economic advancement, allowing indi-
viduals to participate in work, community and family life.
Social networks can, however, also lead to discrimination,
hostility and exclusion.
Living and working conditions comprise the next layer
of influence. It is well known, for instance, that the type
of house in which we live and our environment at work
can affect our health. Work pressure or noisy neighbours
may cause depression and anxiety that can lead to physical
Chapter 10
ill health (Leon and Walt 2001), and physical hazards,
such as dampness, poor architectural design and danger-
ous work practices, can cause disease and injury (Siegnal
and Theorel 2006). Living in deprived neighbourhoods
also increases the risk of ill health and mortality, regardless
of the individual’s personal situation (Steptoe 2006;
Wiles 2008). Much of the legislation passed by the Victo-
rians improved people’s health by tackling problems at
this level (Brunton 2004). Various factory, housing and
sanitation Acts, for example, reduced the incidence of
serious diseases, such as tuberculosis (TB) and typhoid, as
well as improving the quality of people’s lives generally.
Le Fanu (1999) claims that there was a 92% decline in
TB before the introduction of curative drugs. Similar evi-
dence has been put forward by McKeown (1984) who
notes that many life threatening and disabling diseases,
such as poliomyelitis and diphtheria, had radically
declined before the introduction of inoculation. Naidoo
and Wills (2008) conclude that medicine has had only a
marginal influence on health and mortality rates, although
Hubley and Copeman (2008) believe that the under-
utilisation of health services, especially preventative serv-
ices, is a contributing factor to the ill health of the poorer
sectors of society.
The outermost layer affecting our health concerns
general socioeconomic, cultural and environmental con-
ditions. This includes the economic state of the country,
the level of employment, the tax system, the degree of
environmental pollution and our attitudes, for example
towards women, old people, ethnic minorities and disa-
bled people. Increasingly, these factors have taken on
an international dimension as globalisation accelerates
(Pryke 2009). It is at this level that government can be
particularly influential by implementing policy and
passing legislation to bring about wide social change, for
example seat belt legislation (Figure 10.3), banning
smoking in public places and equality legislation, such as
Figure 10.3  Seat belt legislation – influence of government
policy.
189
 Tidy’s physiotherapy
the Sex Discrimination Act (1975), the Disability Discrim-
ination Act (1995) and the Human Rights Act (1998).
It is clear that these levels all interact and influence each
other. If the economic state of the country is favourable,
for example, people are likely to have more disposable
income which may improve their health by allowing them
to buy good quality food and housing of a better standard,
engage in leisure pursuits, give their children more oppor-
tunities and enjoy relaxing holidays to reduce stress. Simi-
larly, if a person is attempting to give up drugs, success is
more likely if community support is strong and if govern-
ment is willing to act by establishing and financing
supportive policies.
Despite the various influences on our health, the evi-
dence suggests overwhelmingly that broad social factors
concerning housing, income, educational level, employ-
ment and social integration are more important than our
individual behaviour or medical practice and advances
(Ewles and Simmett 2003). People of the lowest socioeco-
nomic status are at far higher risk, not only of physical
illness and early death, but also of accidents, premature
births, mental illness and suicide. Smith and Goldblatt
(2004) report that of the 66 major causes of death, 62 are
more prevalent in the lowest two social classes. It is also
the case that men in professional occupations live, on
average, seven years longer than men in manual occupa-
tions and that the children of manual workers are twice as
likely to die before the age of 15 years than the children
of professional workers (Naidoo and Wills 2008). In
addition, Hargreaves (2007) reports that in 2002–4 infant
mortality was 19% higher among manual workers than
professional workers, and that the gap had steadily
widened. Wiles states that ‘…across the lifespan there are
inequalities in people’s health that follow from their eco-
nomic position. Poor people are more likely to be in poor
health and to die at an earlier age’ (2008: 52).
It is important to realise, however, that the health status
of a country does not equate to its wealth, but rather to
how fairly the wealth is distributed (Eberstadt and Satel
2004). Asthana and Halliday (2006) note that longevity
rises in societies which are more equal and socially cohe-
sive, especially when infectious diseases have been con-
trolled. They contend that psychosocial stress is related to
feelings of relative disadvantage and subordinate status
which, in turn, can lead to physical and mental ill health.
It can be disconcerting for healthcare professionals to
realise that there is no obvious correlation between health-
care and health status in any population; indeed, the
health service has sometimes been referred to as an ‘ill
health’ service as it tends to respond when the damage has
been done. This is not to imply, however, that inequalities
in health and healthcare facilities should be tolerated.
Healthcare should be distributed fairly and in accordance
with need. There is evidence, for example, that the uptake
of preventative services, such as birth control and screen-
ing, is low among poor people (Hubley and Copeman
190
2008). This is because of a range of factors that were
summed up by Tudor Hart (1971) in his notion of the
‘inverse care’ law.
The inverse care law
The inverse care law states that those who are most at
risk of acquiring illness and disease are least likely to
receive medical and social services. This is because of a
wide variety of factors relating to social inequalities and
the availability of services.
People with low incomes find it harder to access health-
care services because of social isolation and lack of facili-
ties, such as a car. It is also the case that the areas in which
they live tend to have poor facilities and that health profes-
sionals tend to give them less time and attention than
people who are perceived to be culturally similar to them-
selves (Naidoo and Wills 2008).
There are still many people in the UK who do not fully
benefit from the facilities of the NHS. People from ethnic
minorities are not well served (Atkin et al 2004) nor are
people with learning difficulties (Mencap 2004; DH
2009). As noted in the section on culture, this is a result
of a variety of factors, including poor and inadequate
communication, racism, disablism and lack of cultural
sensitivity.
Different models
Definition
Disability can be defined from an individual model or a
social model. The individual model is dominant and
assumes that the difficulties faced by disabled people are
a direct result of their individual impairments or lack or
loss of functioning. The social model of disability
recognises the social origin of disability in a society
geared by, and for, non-disabled people. The
disadvantages and restrictions, often referred to as
barriers, permeate every aspect of the physical and social
environment. Disability can, therefore, be defined as a
form of social oppression.
In this section of the chapter we will examine two central
models of disability – the individual model and the social
model – to illustrate the ways in which underlying ideas
and concepts can shape physiotherapy practice and wider
medical and social policy. A model can be defined as a
conceptual framework for understanding causal relation-
ships. It usually lies within the framework of a broader
 Changing relationships for promoting health
theory (Brown 2009). Within every society there are
competing models of disability, with some being more
dominant than others at different times (Oliver 2004;
Wilder 2006). In earlier centuries, for example, models of
disability were based upon religion (Stiker 1997; Whalley
Hammell 2006). Although often in conflict, models of
disability may gradually influence and modify each other.
The models put forward by powerful groups within society,
such as the medical profession, tend to dominate the
models of less powerful groups, such as disabled people
themselves (Russell 1998; French and Swain 2008).
It is essential to explore these models of disability, for
attitudes and behaviour towards disabled people, policy,
professional practice, and the running of institutions,
including hospitals and rehabilitation centres, are based,
at least in part, upon them. As Oliver (1993: 61) states:
The ‘lack of fit’ between able-bodied and
disabled people’s definitions is more than
just a semantic quibble for it has important
implications both for the provision of services
and the ability to control one’s life.
Even the ways in which single words are defined can
shape both policy and practice. The word ‘independence’
is an example.
Definition
The predominant meaning of independence is the ability
to do things for oneself. This definition has, however,
been challenged by disabled people who view
independence in terms of self-determination, control,
and managing and organising any assistance that is
required. Some cultures have a collectivist orientation
and do not value independence as much as others. In a
very real sense we are all dependent on each other for
our survival so nobody is independent.
Health professionals tend to define independence as
‘doing things for yourself ’, whereas disabled people define
it as having control of your life. Ryan and Holman state
that ‘…independence is not necessarily about what you
can do for yourself, but rather about what others can do
for you, in ways that you want it done’ (1998: 19).
The individual model of disability
The most widespread view of disability at the present time,
at least in the Western world, is based upon the assump-
tion that the difficulties disabled people experience are a
direct result of their individual physical, sensory or intel-
lectual impairments (French 2004b; Oliver and Sapey;
2006; Whalley Hammell 2006). Thus, the blind person
who falls down a hole in the pavement does so because
Chapter 10
he or she cannot see it, and the person with a motor
impairment fails to get into the building because of his or
her inability to walk. Problems are thus viewed as residing
within the individual. The individual model of disability
is deeply ingrained and ‘taken as given’ in the medical,
psychological and sociological literature. Even in the lit-
erature on the sociology of health and illness, disability as
a social problem is rarely acknowledged (Barnes and
Mercer 1996; Swain et al. 2003; Thomas 2007).
The medical model can be regarded as a subcategory
of the overarching individual model of disability where
disability is conceived as part of the disease process,
abnormality and individual tragedy – something that
happens to unfortunate individuals on a more or less
random basis. In turn, treatment is based upon the idea
that the problem resides within the individual and must
be overcome by the individual’s own efforts. Disabled
people have, for example, been critical of the countless
hours they have spent attempting to learn to walk or
talk at the expense of their education and leisure, and
the way their lives have been dominated by medicine.
especially when they were young (Sutherland 1981;
Oliver 1996; Swain and French 2008). Mason and Rieser
(1992: 82) state:
For young people the disadvantages of medical
treatment need to be weighted against the
possible advantages. Children are not usually
asked if they want speech therapy, physiotherapy,
orthopaedic surgery, hospitalisation, drugs or
cumbersome and ugly ‘aids and appliances’. We
are not asked whether we want to be put on
daily regimes or programmes which use hours of
precious play-time. All these things are just
imposed on us with the assumption that we
share our parents’ or therapists’ desire for us to
be more ‘normal’ at all costs. We are not even
consulted as adults as to whether we think those
things had been necessary or useful.
None of these arguments imply that considering the
medical or individual needs of disabled individuals is
wrong; the argument is that the individual model has
tended to view disability only in those terms, focussing
almost exclusively on attempts to modify people’s impair-
ments and return them or approximate them to ‘normal’.
The effect of the physical, attitudinal and social environ-
ment on disabled people has been largely ignored or
regarded as relatively fixed, which has maintained the
status quo and kept disabled people in their disadvan-
taged state within society (Oliver and Sapey 2006). Thus,
the onus is on disabled people to adapt to a disabling
environment (Swain et al. 2004). This is something that
disabled people are increasingly joining forces to chal-
lenge. As Oliver (1996: 44) states:
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 Tidy’s physiotherapy

The disability movement throughout the world is Physical disability is therefore a particular form of
rejecting approaches based upon the restoration social oppression.
of normality and insisting on approaches based The word ‘physical’ is now frequently removed from
upon the celebration of difference. this definition so as to include people with learning dif-
ficulties and users of the mental health system (French and
Swain 2008). These, and similar, definitions break the
connection between impairment and disability, which are
Definition viewed as separate entities with no causal link. This is
similar to the distinction made between sex (a biological
Normality is a dominant, shared expectation of behaviour entity) and gender (a social entity) in the women’s move-
and personal characteristics that defines what is ment. In recent years, however, it has been recognised
considered culturally desirable and appropriate. that the body is more than a biological entity. Just as
height, weight, age and physique have social and cultural
dimensions and consequences, so too does impairment
(Hughes 2004).
Individualistic definitions of disability certainly have
The WHO’s International Classification of Impairment,
the potential to do serious harm. The medicalisation of
Disability and Handicap (ICIDH) (1980) and the revised
learning disability, whereby people were institutionalised
version (ICIDH-2) (2000) have been rejected by the
and abused, is one example (Ryan and Thomas 1987;
Disabled People’s Movement because, despite taking
Potts and Fido 1991; Atkinson et al. 2000; Goble 2008).
social and environmental factors into account, the
Other examples are the practice of oralism, where deaf
meaning of disability is still underpinned by the medical
children were prevented from using sign language and
model and the causal link between impairment and dis-
punished for using it (Humphries and Gordon 1992;
ability remains intact (Hurst 2000; Pfeiffer 2000).
Dimmock 1993; Corker 1996) and ‘sight-saving’ schools
Disability is viewed within the social model in terms of
where visually impaired children were prevented from
barriers (French 2004b). There are three types of barriers,
using their sight and, in consequence, were denied a full
which all interact:
education (French 2005). All of these policies and prac-
tices were rooted in an individual model of disability. • Structural barriers: these refer to the underlying norms,
mores and ideologies of organisations and institutions
which are based on judgements of ‘normality’ and
The social model of disability which are sustained by hierarchies of power.
The social model of disability is often referred to as the • Environmental barriers: these refer to physical barriers
‘barriers approach’ where disability is viewed not in terms within the environment, for example steps, holes in
of the individual’s impairment, but in terms of environ- the pavement and lack of resources for disabled
mental, structural and attitudinal barriers that impinge people, for example lack of Braille and lack of sign
upon the lives of disabled people and which have the language interpreters. It also refers to the ways things
potential to impede their inclusion and progress in many are done, which may exclude disabled people, e.g.
areas of life, including employment, education and leisure, the way meetings are conducted and the time
unless they are minimised or removed (Oliver 1996). The allowed for tasks.
social model of disability has arisen from the thinking,
writings and growing cultural identity of disabled people
themselves (Swain et al. 2004).
The following definition of impairment and disability
is that of the Union of the Physically Impaired Against
Segregation (UPIAS), which was an early radical group of
the Disabled People’s Movement. Its major importance is
that it breaks the link between impairment and disability
(UPIAS 1976: 14):
• impairment: lacking part or all of a limb, or having a
defective limb, organ or mechanism of the body.
• disability: the disadvantage or restriction of activity
caused by a contemporary social organisation which
takes no or little account of people who have
physical impairments and thus excludes them from
participation in the mainstream of social activities. Figure 10.4  Whose problem?

192
 Changing relationships for promoting health
Figure 10.5  Reading Braille.
Figure 10.6  Out of order.
• Attitudinal barriers: these refer to the adverse
attitudes and behaviour of people towards disabled
people.
It can be seen that the social model of disability locates
disability not within the individual disabled person, but
within society. Thus, the person who uses a wheelchair is
not disabled by paralysis but by building design, lack of
lifts, rigid work practices, and the attitudes and behaviour
of others (Figure 10.4). Similarly, the visually impaired
person is not disabled by lack of sight, but by lack of
Braille and large print, cluttered pavements and stereotypi-
cal ideas about blindness (Figure 10.5). Finkelstein (1981,
1998) has argued that non-disabled people would be
equally disabled if the environment were not designed
with their needs in mind, for example if the height of
doorways only accommodated wheelchair users (Figure
10.6). Human beings fashion the world to suit their
own capabilities and limitations, and disabled people are
wanting nothing more than that.
Chapter 10
CHANGING RELATIONSHIPS
Partnership and user involvement
Definition
Looked at broadly, partnership refers to organisations or
individuals working together or acting jointly.
In recent policy developments partnership has been a
dominant concept signifying the attainment of greater
equality in professional–client relations generally. At a
policy level, partnership and collaborative working is con-
sidered to be a ‘good’ thing. Governments of all persua-
sions have placed emphasis on the need for different
agencies to work together to provide more ‘seamless’ and
‘joined-up’ service provision by moving towards more
integrated health and social care provision (DH 2000a).
Partnership-associated terms
• Inter-agency collaboration.
• Joint working.
• Multi-professional practice.
• Service user involvement.
• Client-centred practice.
Partnership in terms of policy, practice and provision
has become a buzz word, widely accepted as an imperative
in the development of services for disabled people (and
other service users). Defining the concept of partnership,
however, is difficult because partnership means different
things to different groups of people. It is associated with
numerous other terms such as ‘participation’ and ‘empow-
erment’, and also encompasses different relationships.
1. Partnership refers to the relationship between
professionals and professional organisations.
Associated terms include ‘inter-agency collaboration’,
‘joint working’ and ‘multi-professional practice’.
2. Partnership refers to the relationship between service
users and the service system. A key term here is
‘service user involvement’. This is, again, mandated
within policy. For instance, one of the Department of
Health’s (DH) six medium-term priorities was that
health authorities should (DH 1995: 9):
… give greater voice and emphasis to users of
NHS services and their carers in their own care,
the development and definition of standards set
193
 Tidy’s physiotherapy
for NHS services locally and the development of
NHS policy both locally and nationally.
3. Though much less recognised, the term ‘partnership’
can be applied to relationships between disabled
people and other service users, to include partnerships
within and between organisations of disabled
people. Barnes and Mercer (2006: 91–92) state:
The gap between disabled people’s expectations
and their actual involvement in the statutory
and voluntary sectors has reinforced claims from
disabled people’s organisations that the move to
a more equal and democratic society demands a
bottom-up approach to politics and policy-
making. Its potential is realised by the
emergence of active user-led organisations.
4. The term ‘partnership’ also refers to the more
immediate relationship between a professional and a
service user. Again, this can encompass different
terms such as ‘client-centred practice’. Sumsion
(2005: 100) defines this as follows:
In the UK client centred occupational therapy
is a partnership between the client and the
therapist that empowers the client to engage
in functional performance and fulfil their
occupational roles in a variety of environments.
The clients participate actively in negotiating
goals that are given priority and are at the
centre of assessment, intervention and
evaluation.
In terms of more detailed breakdowns of the meaning
of the term partnership, Reynolds (2004) suggests that a
partnership approach to healthcare makes the following
assumptions:
• both professionals and service users are regarded as
bringing strengths or resources to the therapeutic
process and the therapeutic relationship;
• both professionals and service users are part of the
team that will openly share information and make
decisions about the ways forward in therapy;
• the relationship is respectful and affirmative, rather
than shaped by dependency, submissiveness or
power struggles;
• the relationship is based on adult strategies of
communication, rather than infantalising,
manipulation or stereotyping, with both partners
having a respected voice in the interaction;
• the service user is motivated to share responsibility
with the therapist for the therapy process and outcome;
• the purpose of the partnership is to promote the
service user’s self-actualisation, development and
194
quality of life rather than pressurising specifically for
better compliance with treatment.
Partnership in therapy practice could include the service
users’ voices in the following decision making processes
(Thompson 1998: 213):
• identifying problems to be tackled, issues to be
addressed, goals to be achieved;
• deciding what steps are to be taken and who needs
to do what;
• undertaking the necessary work through
collaboration and consultation;
• reviewing progress and agreeing any changes that
need to be made to the agreed course of action;
• bringing the work to a close if and when necessary;
• evaluating the work done, highlighting strengths,
weaknesses and lessons to be learned.
Definition
Inclusive communication is the valuing and celebration of
differences and empowerment through the power of
communication. The following factors are central:
• participation;
• accessible communication;
• diversity and flexibility;
• human relations;
• inclusive language.
The term ‘inclusion’ has been seen by many as a process
of social change, rather than a particular state (Ballard
1999), and this can be seen to apply equally to commu-
nication and relationships. To develop this notion of an
inclusive communication environment, we shall conclude
this section by tentatively offering some general principles
based on our previous discussion.
Participation
Priority needs to be given to the participation of service users
in the planning and evaluation of changing policy, provision
and practice in developing inclusive communication. The
onus is on service providers to face the challenges of ena-
bling true participation of service users in decision-making
processes, recognising that service users wish to participate
in different ways. These include the democratic representa-
tion of the views of organisations of service users. Participa-
tion also includes as wide a consultation process as possible.
Service users often continue to be treated as passively
dependent on the expertise of others yet control has become
increasingly central to social change for service users. As a
 Changing relationships for promoting health
disabled man interviewed by French (2004a: 106), with a
great deal of experience of therapy treatment, states:
Users should have more power. Until you give
users real power, real control we’ll get nowhere
… there’s an awful lot of people with a lot of
vested interests. The more we shout about rights
the more people get afraid. I’d like to see
therapy training following the social model
rather than the medical model. The only way to
do it is to get much more input from disabled
people into the training.
The relationship between disabled people and health
professionals has never been an easy one, for it is an
unequal relationship with the professional holding most
of the power. Traditionally, the professional worker has
defined, planned and delivered the services while the disa-
bled person has been a passive recipient with little, if any,
opportunity to exercise control (French and Swain 2001).
Disabled people’s definitions of the problems they face,
and the appropriate solutions to such problems, have gen-
erally been given insufficient weight, thereby seriously
hampering the rehabilitation process – if there is no con-
sensus, little real progress can be made.
While physiotherapists may feel constrained by their
working role, there usually remains some degree of flexi-
bility in which they can work in partnership with disabled
people and other patients and clients. For example, they
can share power by sharing ‘expert’ knowledge and infor-
mation, and they can encourage patients and clients to
participate actively in the writing of reports and case files
so that their voices are heard and their viewpoints repre-
sented in official documents.
Awareness of disability by all those who work in physi-
otherapy departments can be encouraged and developed
through disability equality training run by skilled disabled
people. Disability equality training is (French 1996: 121):
… primarily about changing the meaning of
disability from individual tragedy to social
oppression; it emphasises the politics of
disability, the social and physical barriers that
disabled people face, and the links with other
oppressed groups.
Another way in which physiotherapists can work in
partnership is by recognising and acknowledging the
disabled person’s expertise in relation to the meaning
and experience of being disabled and their particular
impairment. This means encouraging disabled people to
exercise choice of services appropriate to their desired
lifestyles. Physiotherapists can work in partnership with
disabled people by regarding themselves as a resource
(expertise, information, advocacy) so that disabled people
Chapter 10
can work towards achieving their own goals. This would
include clarifying the goals to which the disabled person
aspires, identifying the barriers that may prevent the reali-
sation of those goals and working towards removing the
barriers.
From the perspective of the social model of disability,
professional power can be used to highlight the shortfall
in resources for disabled people, to ensure that the voices
of disabled people are heard and responded to, and to
encourage and support disabled people to assert them-
selves so that their expertise about disability is at the centre
of the development of services and support. It is important
that physiotherapists, and all other staff in physiotherapy
departments, make a conscious decision to heighten their
awareness of disability as an area of inquiry.
Accessible communication
The issues around language and ethnicity are complex, but
there are many examples of good practice. The Sandwell
Integrated Language and Communication Service (SILCS)
in the West Midlands, for instance, involves a range of
local health organisations – health authorities, NHS
Direct, primary care groups, local authorities and volun-
tary agencies – working together to provide a pooled
resource for spoken, written and telephone translation
and interpreting, as well as sign language interpreters
(Douglas et al. 2004). Accessibility of communication,
however, needs management beyond such a resource,
including training for staff on using interpreters. The pro-
vision of written information in a range of languages
must ensure that translations meet the information
needs of black and ethnic minority communities and
are culturally relevant. There are, of course, many social
factors within the diversity of the needs of people from
black and ethnic minority communities. As Dominelli
(1997: 107) argues, for instance, ‘…translation services
should be publicly funded and provide interpreters
matched to clients’ ethnic grouping, language, religion,
class and gender’.
Much is known about the accessibility of information
based on the views expressed by disabled people. Clark
(2002) offers wide-ranging recommendations which
cover such things as alternative formats, for example, large
print, Braille, accessible websites, videotape and British
Sign Language, and suggestions for plain written language,
layout, typeface and font size. For some people, particu-
larly those with communication disabilities, the issue
of time can be crucial to an inclusive communication
environment. For people with communication disabilities
a slower tempo can be the only accessible pace to ensure
understanding. A participant within the research by
Knight et al. (2002: 17) explains:
I would rather repeat myself ten times than
have someone finish a sentence for me. This is
195
 Tidy’s physiotherapy

why I won’t use a communication aid. I prefer
to speak for myself and I would rather repeat
myself several times than have someone say they
understood me when they did not.
Along similar lines, Pound and Hewitt (2004) em­phasise
that access in meetings with people with communication
impairments requires attention to their length and timing.
Diversity and flexibility
Responding to diversity and being flexible are complex
issues as Douglas et al. (2004: 74) point out:
a relationship; it constitutes the initiation, maintenance
and ending of a relationship; and it is the medium and
substance through which the relationship is defined and
given meaning. A disabled client offered advice to thera-
pists on the basis of her experience (French 2004a: 103):
Forget you’re a therapist – just be yourself. I
don’t mean forget all your training – but be
yourself. Don’t be afraid of showing the real you
because that’s what makes people respond, when
they’re ill they respond more easily if the
therapist is being real.

Interpreting is extremely complex in that

interpreters must ensure that the patient or
client easily understands the language they use.
Again other factors, such as class, region,
religion and geography, may impinge on the
process of interpreting and communication
– such that just speaking the same language
may not necessarily mean the same
understanding will follow.
A disabled client interviewed by French (2004a: 103)
provides the foundation for this by questioning the focus
on ‘normality’, rather than being flexible and taking the A
client’s perspective into account:

What concerns me most of all is this focus on

trying to make me ‘normal’. I get that from all
the therapists. I get a lot of referrals of ‘this may
help’ and ‘that may help’. They had a massive
case conference before the adaptations – it was a
case of ‘how normal can we make her first? Are
the adaptations necessary?’
The lists of recommendations for communication
access, as produced by Clark (2002) and others, clearly
challenge the imperatives of ‘normality’ and emphasise
the diversity of communication styles and formats (Figure
10.7). Nevertheless, there are diverse needs even within
specific groups of people with impairments, which, again,
puts the emphasis on listening to individual people and
giving them control. Sally French, as a person with a visual
impairment, has found, for example, that she is often
presented with large print even though it is the depth, font
and colour contrast that are more important to her.

Human relations
Communication is constructed and embedded in rela­
tionships between people. The notion of personal rela- B
tionships can be seen as irrevocably intertwined with
communication. Communication is a means of expressing Figure 10.7  There are many ways to communicate.

196
 Changing relationships for promoting health
Use of inclusive language
Inclusive language reflects the idea that language controls
or constructs thinking. Sexism, ageism, homophobia,
racism and disablism are framed within the very language
we use. This has been characterised and degraded by some
people as ‘political correctness’ (PC), often with reference
to examples seen as trivial or fatuous (e.g. being criticised
for offering black or white coffee). Use of language,
however, is not simply about the legitimacy of words
or phrases – what we are allowed to say or not say. As
Thompson (1998) explains, language is a powerful vehicle
within interactions between health and social care profes-
sionals and clients. He identifies a number of key issues:
• jargon: the use of specialised language, creating
barriers and mystification, and reinforcing power
differences;
• stereotypes: terms used to refer to people that
reinforce presumptions, e.g. disabled people as
‘sufferers’;
• stigma: terms that are derogatory and insulting, e.g.
‘mentally handicapped’;
• exclusion: terms that exclude, overlook or marginalise
certain groups, e.g. the term ‘Christian name’;
• depersonalisation: terms that are reductionist and
dehumanising, e,g, ‘the elderly’, ‘the disabled’ and
even ‘CPs’ (to denote people with cerebral palsy).
In this light, questions of the use of language go well
beyond listing acceptable and unacceptable words to
examining ways of thinking that rationalise, legitimise and
underline unequal therapist–client power relations.
Definition
Service user involvement is a general term that covers
service user consultation and collaboration in service
policy making, planning, delivery and evaluation. It can
involve:
• giving users information about what others have
decided;
• consulting users;
• making joint decisions with users;
• users doing things for themselves and taking control.
In terms of partnership encompassed within the notion
of service user involvement, the literature suggests that
methods of involving users of services can take many
forms. For instance, Brown (2000) lists the following
methods with particular reference to residential care for
disabled people:
• residents’ committees;
• user panels;
• customer surveys;
• suggestion boxes;
Chapter 10
• involvement in management committees;
• involvement in forums and working parties;
• focus groups;
• public meetings.
It is crucial not to rely heavily on any one method as
none is perfect and a variety are needed to reach all disa-
bled people.
The following principles were derived from the evalua-
tion of user involvement in a disabled people’s organisa-
tion (Swain et al. 2005). They do not rely on any particular
method, but focus on general principles to provide both
the foundations for development and a framework for
monitoring change through user involvement.
• There is a clear and absolute requirement that the
effective development of user involvement must be
generated by and controlled by service users
themselves.
• The development of user involvement needs to be
seen as embedded in all decision-making within the
organisation, including financial and management
decision-making at all levels (local, regional and
national).
• User involvement is embedded in service users’ lives.
It is part of defining the quality of life for service
users. Quality of life is determined within the say
that people have over their lives, from the day-to-day
decisions over basic needs (sleep, eating, toilet, etc.)
to the control over their own finances and over the
support they receive.
• There is no existing model of user involvement that
has been developed that can, or should be, adopted
for general usage. Any attempt to do so is more
likely to be retrograde than enhance user
involvement.
• There is no body of concern that can be seen as ‘user
involvement’ that is separate or isolated from all
decision-making structures and processes within an
organisation – finance, management, etc.
• User involvement in policy-making is crucial. Firstly,
service users should be involved in the writing of
policy, rather than being simply consulted about
drafts of policy statements. Secondly, the least
restrictive possible policies and practices arising from
legislation need to be implemented. Thirdly, in
adopting the least restrictive response policy-making
should, as far as possible, be made at a local level,
with full user involvement.
• Approaches to user involvement also need to be
open, flexible and individual (or client-centred).
• Effective communication is fundamental to user
involvement. This includes increased support,
communication workers and use of communication
equipment at an individual level. It also includes a
creative and flexible approach to group meetings,
including video conferencing, to open opportunities.
197
 Tidy’s physiotherapy
Looking towards inclusion, Bewley and Glendinning
(1994) note a heavy reliance on formal meetings in service
user involvement and point out that in order to reach
black disabled people, people living in rural areas and
other marginalised groups, such as travellers and people
with learning difficulties, a community development
approach, working with local networks, needs to be
adopted on a sustained basis.
Turning to the standpoint of disabled people, Beresford
et al. (1997) note that organisations of disabled people
have influenced mainstream services by collaborating on
projects and by training professionals in disability issues.
Some disabled people feel that this collaboration is stra-
tegically important to ensure their involvement in com-
munity care, though others are more cautious fearing that
professionals will become too dominant. In their research
into self-organised user groups of social and healthcare
services, Barnes et al. (1999: 24) found that the representa-
tion of disabled people within key decision-making forums
was seen as both an end in itself and a means for achieving
other objectives. For instance, one participant stated:
I think the patients’ council works well because
it does work on the principle that it’s not one or
two of our service users … sitting on the edge of
a meeting or whatever, it is managers, senior
managers coming to meetings of service users to
be accountable and really they have to account
on the spot.
A very important component of user involvement has
been the development of services that are run and control-
led by disabled people for disabled people. Drake (1996:
190) states that:
… disabled people have been increasingly active
not only in policy debates but also in producing
self-governed groups and projects such as CILs
[Centres for Independent (or Integrated)
Living] which have proved a cogent and
powerful alternative to the traditional gamut of
projects like day centres and social clubs.
Centres for Independent (or Integrated) Living (CILs)
provide a range of services that are designed to meet the
needs of disabled people as they define them. These
include the provision of information, advice and associ-
ated support services; training in the employment of
personal assistants; repair services; peer counselling; inde-
pendent advocacy; and disability equality training. Mercer
(2004: 179) believes that:
There is a broad consensus that user-led
organisations offer a distinctive approach to
198
service provision. This encompasses adherence to
a social model, democratic accountability,
promoting independent/integrated living through
wider user choice and control and including all
disabled people.
From her review of the literature on user involvement
Carr (2004: 12) states:
Evaluation of user-led organisations for disabled
people has shown that there was overwhelming
agreement that user-led organisations were far
more responsive to disabled people’s support
needs both in terms of what was on offer and
how it was delivered, with peer support a major
consideration.
It is not surprising, then, that Thompson (2001) argues
that CILs can act as a model for service provision. If we
return to the four relationships or types of partnerships
outlined above, they can be viewed as inter-related. The
partnership between disabled people themselves is a key
to shifting the power relations between service providers
and service users.
Disability studies (the social, political and cultural anal-
ysis of disability) have barely touched the curriculum of
health professionals, including physiotherapists, but with
the growing impact of the social model of disability and
changes such as the implementation of the Disability
Discrimination Act (1995), physiotherapists will need to
extend their viewpoint beyond the individual model of
disability and to work with disabled people as equal part-
ners. This may mean moving away from the traditional
approach of ‘helping’ and ‘treating’ towards a much
broader brief that involves joining forces with disabled
people and using their professional power, in collabora-
tion and partnership with disabled people, to dismantle
every aspect of disablism and to further the fight for full
citizenship for all disabled people.
Health promotion
The profession of physiotherapy, along with other health-
care professions, has taken a largely biomedical approach
to patient and client care (Hubley and Copeman 2008).
This is strongly reflected in physiotherapy literature and
research, and the undergraduate curriculum (French and
Swain 2005). Over the years, however, education in the
social sciences has been included and more physiothera-
pists now work in the community rather than hospitals,
reflecting changes in NHS structure and policy (DH
2000b). Physiotherapy has, until recent times, been under
 Changing relationships for promoting health
Definition
Health promotion is a broad range of activities that aim
to improve health. These include health education, such
as teaching correct lifting techniques; environmental
measures, such as the control of pollution; preventative
medicine, such as cervical screening; fiscal measures,
such as financial benefits; and legal measures, such as
seat belt legislation.
the control of doctors, and physiotherapy practice, with
its biomedical orientation, has reflected this control.
Naidoo and Wills (2008) point out that medicine has
focussed on the individual and that this has been perpetu-
ated by the greater power of medical professionals when
compared with those who work in health promotion.
They also note that few resources are allocated to health
promoting practices. A consideration of social, political,
cultural and economic factors that may impact on people’s
health and well-being has been slow to develop in physi-
otherapy education, and the social sciences remain mar-
ginalised and focussed largely on micro issues, such as
interpersonal communication.
This section of the chapter aims to uncover the meaning
of health promotion in physiotherapy practice. Health
promotion is a complex and contested concept which is
defined in many ways (Scriven 2005). This is not surpris-
ing given that, as noted above, the notion of health itself
has a wide range of meanings from the physiological to
the philosophical and spiritual. Tones and Tilford (2001:
2) state that health promotion:
… means different things to different people.
Since health itself is a multi-dimensional notion
– open to multiple interpretations – it is
unsurprising that the definition of health
promotion is itself problematic.
The development of health promotion stretches back to
the nineteenth century. The 1848 Public Health Act for
England and Wales, for instance, required local authorities
to provide sewage disposal systems and a clean water
supply. Ewles and Simnett (2003) trace the development
of health promotion throughout the twentieth century. In
the first half of the century the main concern was ‘public
health’ which saw, for example, the clearance of the slums,
the building of new towns and legislation aimed at reduc-
ing environmental pollution. Between 1950 and 1970 the
emphasis changed to health education where people were
given information designed to persuade or coerce them to
change their ‘unhealthy’ behaviours as a way of preventing
disease. School children, for example, were provided with
Chapter 10
information about a balanced diet in order to prevent
diseases such as diabetes and coronary heart disease in
later life. Women were given pre- and postnatal advice and
instruction by physiotherapists, including pelvic floor
exercises, in order to reduce complications such as stress
incontinence after birth. People were urged to take part in
screening programmes and to have their children inocu-
lated against diseases such as poliomyelitis and diphtheria
which can lead to impairment or death.
Definition
Victim blaming is a tendency to blame the person who is
experiencing ill health or other difficulties. A heavy
smoker, for example, may be blamed for contracting
lung cancer. Victim blaming denies the influence of wide
social, economic, cultural and political factors on people’s
behaviour, over which they may have little control.
Behaviour cannot be separated from the social context in
which it takes place.
Health education, however, came under criticism on the
grounds that it leads to a ‘victim blaming’ approach
(Naidoo and Wills 2008).
As noted in the discussion on health inequalities, people
in deprived circumstances have the fewest choices, includ-
ing those concerning their health. It may, for example, be
more difficult or impossible for them to find the time to
exercise regularly, to attend health-screening and health
education programmes, or to afford a balanced diet. Fur-
thermore, environmental factors, such as noise, pollution
and poor housing impact on their physical and mental
health to a greater extent than their more affluent peers.
Tones and Tilford (2001: 7) state:
… a focus on individual sins of omission and
commission characterised the approach of
preventive medicine and health education
for the better part of the 20th century.
Increasingly, however, explanations of the
determinants of health and disease is shifting
away from this narrow orientation on individual
behaviours and beginning to emphasise the
importance of environmental factors.
Behaviours labelled unhealthy may be rational strat­
egies to reduce stress caused by wider social and economic
factors. Thus, a single mother who lives in a high-rise flat
in a run down part of town may smoke or over-eat in
order to cope with her difficult situation. Trying to
prevent her from smoking or over-eating may be both
199
 Tidy’s physiotherapy
counter-productive and damaging because, for her, the
emotional gains outweigh the physical costs. Hubley and
Copeman (2008) speak of a ‘culture of poverty’ where
poor and marginalised people develop coping mecha-
nisms for their own psychological and emotional survival
which may be dysfunctional with regard to their physical
health.
As Nadoo and Wills (2008: 151) state:
There is a limit to a person’s capacity to adapt.
For example those living on low incomes will be
stretched by coping with poverty and its
uncertainties. Having to make changes to their
health behaviour may be too much to expect for
people whose lives are already problematic.
Focussing on individual behaviour also has the effect of
deflecting interest from wider social, economic and politi-
cal issues. As Ewles and Simnett (2003: 41) state:
We cannot assume that individual behaviour is
the primary cause of ill health … There is a
danger that focussing on the individual detracts
attention from the more significant (and, of
course, politically sensitive) determinants of
health, such as the social and economic factors
of racism, relative deprivation, poverty, housing
and unemployment.
Focussing on people’s responsibility for their own
health can easily serve to legitimate inactivity from both
professionals and government.
From the 1980s what is sometimes known as the ‘new
public health’ emerged. This focusses on both public
health and health education and aims to involve people
and their communities (Nutbeam and Harris 1999). It
encompasses traditional healthcare, personal social serv-
ices, preventative healthcare, community-based work (e.g.
the establishment of self-help groups, pressure groups,
community facilities and activities), organisational devel-
opment (e.g. equal opportunity policies and measures to
reduce stress), public policies (e.g. education, housing
and transport), environmental policies (e.g. smoke-free
zones and noise control) and legislative change (e.g.
the labelling of food and the control of advertising).
Broad programmes operate at multiple levels and address
a wide range of health related problems that can be
present in a population. It requires communication and
co-operation among many different agencies, as well as
‘joined up’ policy (Nadoo and Wills 2008). In addition,
increasing globalisation creates new challenges as health
promotion moves beyond national boundaries. Interna-
tional bodies such as the WHO and the World Bank, for
instance, are at the forefront of many international health
projects.
200
The term ‘health promotion’ refers to strategies that
not only attempt to prevent ill-health and disease in its
broadest sense, but also to improve quality of life and
well-being. This is in contrast to the biomedical approach
where the emphasis is on finding a cure or managing a
condition once it has occurred. Most definitions of health
promotion emphasise the need to empower people to
have more choice and control over those aspects of their
lives which affect their health including the communities
in which they live. There is a recognition that medicine
and professional practice have had little effect on health
and that health can be improved more successfully by
investing in the physical and social fabric of society and
reducing inequalities (Ewles and Simnett 2003). Hubley
and Copeman (2008) argue that health services need to
be reshaped away from medicalisation and towards the
empowerment of patients and clients.
Naidoo and Wills (2008) see health promotion as
encompassing disease prevention, health education and
health information, public health reform and community
development. They view the work of those involved in
health promotion as emphasising a focus on health not
illness, the empowerment of clients, recognising that
health is multi-dimensional and acknowledging the
influence of factors external to the individual which
impinge upon their health. When attempting to deal
with a health issue such as smoking, for example, a wide
range of health-promoting activities are necessary, such as
health education, developing assertiveness skills, commu-
nity development, such as organising a ‘healthy eating’
campaign, and structural adjustments, such as legislation
to ban cigarette advertising and smoking in public places.
They emphasise that a diverse range of information and
theories are needed in the practice of health promotion
drawn from epidemiology, demography and the social
sciences, as well as information about particular com­
munity needs and priorities. Ewles and Simmett (2003)
list the following approaches to health promotion which
are not, necessarily, mutually exclusive.
• The medical approach. This approach values
preventative measures (such as screening and
inoculation) and patient compliance.
• The behavioural change approach. This approach seeks
to change people’s attitudes and behaviour in ways
defined by the professional.
• The educational approach. This approach gives people
information but their values and choices are
respected. The role of the professional is to help
people to gain the skills to make well-informed
decisions and to offer their help and support.
• The client-centred approach. This approach
identifies what patients and clients want to know
and what actions, if any, they want to take. Self-
empowerment is central and the professional acts as
a facilitator.
 Changing relationships for promoting health Chapter 10

• The social change approach. This approach focusses within individual lives, within the communities in which
overtly on political issues and on changing society, people live and within the world. Physiotherapists and
rather than changing individuals. other health professionals are playing their part in many
aspects of health promotion (see Scriven 2005), but
It would seem from the literature and from first-hand mostly in the areas of preventative medicine and health
accounts from physiotherapists (see French and Swain
2005) that physiotherapy practice reflects most strongly
the first three approaches listed above. In the Curriculum
Framework for Qualifying Programmes in Physiotherapy (2002),
for instance, the Chartered Society of Physiotherapy
define health promotion in terms of providing advice
and health education to patients, carers, support workers
and other healthcare professionals. Talking of clients with
learning difficulties, however, Standing (1999), a phys­
iotherapist, moves towards the client-centred approach.
She advocates working in partnership with patients and
clients in order to fulfil their unique goals and aspira-
tions and, as a consequence, to improve their health and
well-being.
In 1996 the first international conference on health
promotion was held. It led to the Ottawa Charter for
Health Promotion which proposed the following five
areas for action:
• building a public health policy;
• creating supportive environments;
• developing personal skills;
• strengthening communities;
• re-orientating health services.
(Adapted from Naidoo and Wills 2008.)
Physiotherapists (and other health professionals) are
rarely involved in the social change approach advocated
here. Many sociologists and disabled people have criti-
cised this stance which, they claim, not only maintains the
status quo but, through the power of professionals, defines
the very meaning of illness, disability and mental distress
(Naidoo and Wills 2008). Davis (2004), a disabled activ-
ist, for example, is fervent in his criticism of health profes-
sionals’ lack of interest and involvement in the disability
rights agenda. Similar critiques of medical professionals
A
and healthcare services have been voiced over many years
by sociologists such as Friedson (1970), Illich (1976) and
McKnight (1995), and feminists such as Doyal (1995).
Naidoo and Wills urge health professionals to become
more involved in political activity to combat the social
and economical determinants of ill-health. They state
(2008: 110–111) that:

Accepting the status quo is not an apolitical

position but a deeply political one … part of the
task of health promoters is to uncover and hold
up to scrutiny their values and beliefs.

Health promotion is a broad and complex concept B

which demands of physiotherapists a comprehensive
understanding of the meaning of health and well-being Figure 10.8  What does this have to do with health?

201
 Tidy’s physiotherapy

education. Central to moving towards more health-

promoting practice is shifting the emphasis from medical
and behavioural change approaches towards more client-
centred and social change approaches. This shift would
involve a broadening of the physiotherapist’s role and
working in partnership with those engaged in health pro-
motion outside ‘traditional’ health and social services,
such as architects, community workers and political cam-
paigners. This would involve many skills, not least those
of communicating with a wide range of people from
diverse disciplines. As Scriven (2005) points out, this is no
easy task within the NHS where resources are restricted
and where curing disease takes precedent over promoting
health. A holistic approach towards health and well-being
challenges a medicalised view of individuals and extends
thinking and activity beyond the individual to the broad
social, economic, cultural and political context locally,
nationally and internationally (Figure 10.8).
CONCLUSION
In this chapter we have examined relationships within
physiotherapy practice and have discussed how these rela-
tionships might change to encompass current reasoning,
knowledge, policy and legislation. As front line workers in
the NHS it is vital that physiotherapists understand the
meaning of health, illness and disability from the perspec-
tive of patients and clients, and that the physiotherapy
service is run flexibly and imaginatively so that people
who may benefit from it can use it with ease and conven-
ience and in ways that facilitate their aspirations and
goals. Improving health, in its broadest sense, is not just
about medicine, but necessitates involvement in areas
such as housing, employment, education, leisure, out-
reach services and community regeneration. It also
demands working with rather than on or for people.

ACKNOWLEDGEMENTS

With a special thank you to Lauren and Iris.

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 Chapter
Musculoskeletal assessment
Lynne Gaskell
INTRODUCTION
Students are often in awe of qualified clinicians who assess
and make complex clinical reasoning decisions in real
time with apparently little effort. Becoming competent in
patient assessment, like most things in life, takes practice,
refinement and reflection, and it looks easy when per­
formed by an expert. The ability to effectively examine and
assess patients is an essential skill for physiotherapists to
possess. This chapter introduces some important princi­
ples of musculoskeletal assessment. It provides an illus­
trated guide to many of the important techniques and tests
that are valuable tools in the arsenal of the chartered
physiotherapist. Furthermore, it provides some assessment
templates for specific joints of the body. The objectives of
this chapter are:
• to identify the appropriate questions to include in a
subjective musculoskeletal assessment;
• to discuss the use of regional and special questions
for particular joints;
• to explain the use of appropriate subjective and
objective markers;
• to explain the use of specific and regional tests at
particular joints;
• to recognise the need for continuous reassessment.
This chapter includes templates for assessment of the
lumbar spine (including a biopsychosocial assessment),
the cervical spine, the shoulder, the hip, the knee, the
ankle and the foot.
GENERAL ISSUES
Since 1977, chartered physiotherapists in the UK have
been able to work as autonomous practitioners, making
11 
treatment decisions independently of other medical pro­
fessionals. This professional autonomy makes the pro­
fession stimulating and exciting, but with it comes a
great deal of responsibility. Upon qualifying, physiothera­
pists are legally responsible for their actions and treat­
ments. Increasing numbers of physiotherapists now work
in the primary care setting and this trend is likely to con­
tinue. Allowing patients direct access to physiotherapists
could relieve other medical practitioners of considerable
workload.
Recent years have seen the introduction of extended-
scope practitioners, clinical specialist and consultant
physiotherapy posts. Physiotherapists in these roles are
assessing patients usually referred by general practitioners
(GPs) who would otherwise have been examined by a
consultant orthopaedic surgeon. These practitioners are
required to possess excellent assessment skills, a wide
experience of different clinical conditions and patholo­
gies, and to be able to recognise the appropriate course of
action for that particular patient. Audits of these interven­
tions have been encouraging; Gardiner and Turner (2002)
found that the extended-scope practitioners showed more
consistency between clinical diagnosis and arthroscopic
findings in the knee than did their medical counterparts.
In the present climate, these posts, along with the newly
established consultant physiotherapist role, are likely to
expand and in doing so will deservedly raise the profile of
the physiotherapy profession.
When should physiotherapists
assess patients?
• On first patient contact, it is essential to perform an
initial assessment to determine the patient’s
problems and to establish a treatment plan.
• During the treatment, assessment is particularly
appropriate while performing treatments such as
207
 Tidy’s physiotherapy
mobilisations and exercises when the patient’s signs
and symptoms may vary quite rapidly. Be aware of
any improvement or deterioration in the patient’s
condition as and when it occurs.
• Following each treatment, the patient should be
reassessed using subjective and objective markers in
order to judge the efficacy of the physiotherapy
intervention. Assessment is the keystone of effective
treatment without which successes and failures lose
all of their value as learning experiences. Subjective
and objective markers are explained later in this
chapter.
• At the beginning of each new treatment, assessment
should determine the lasting effects of treatment or
the effects that other activities may have had on the
patient’s signs and symptoms. In reassessing the
effect of a treatment, it is essential to evaluate
progress from the perspective of the patient, as well
as from the physical findings.
Format of the assessment
• Listen – history and background.
• Look – observation.
• Test – individual structures (range of movement,
strength).
• Record – an accurate account of findings.
• Assess – and remember to involve the patient.
Aims of the subjective assessment
The aims of subjective assessment are to gather all relevant
information about the site, nature, behaviour and onset
of symptoms, and past treatments. Review the patient’s
general health, any past investigations, medication and
social history. This should lead to a formulation of the
next step of physical tests.
Definition
Symptoms are what the person complains of (e.g. ‘my
knee hurts’). Signs are what can be measured or tested
(e.g. the patient has a positive patellar tap test).
Aims of the objective assessment
The objective assessment aims to seek abnormalities of
function, using active, passive, resisted, neurological and
special tests of all the tissues involved. This may be guided
by the history. However, it is important to conduct all tests
208
objectively and equally, and not attempt to bias the find­
ings in an attempt to make the hypothesis fit.
Objective examination is concerned with performing
and recording objective signs. It aims to:
• reproduce all or parts of the patient’s symptoms;
• determine the pattern, quality, range, resistance and
pain response for each movement;
• identify factors that have predisposed or arisen from
the disorder;
• obtain signs on which to reassess the effectiveness of
treatment by producing reassessment ‘asterisks’ or
‘markers’ (Jull, 1994).
SUBJECTIVE ASSESSMENT
Initial questioning
Subjective assessment needs to include the name, address
and telephone number of the patient, and the patient’s
hospital number, if appropriate. Both the age and the date
of birth of the patient should be recorded. The medical
referrer’s name and practice should also be recorded for
correspondence, discharge letters, etc.
It is also essential for the physiotherapist to obtain suf­
ficient details of the patient’s employment. Is the patient
currently working? If not, determine the reasons for this.
Is it because the person is unable to cope with the physical
demands of the job? Do heavy lifting, repetitive move­
ments or inappropriate sustained postures increase the
symptoms? These factors may be precursors of poor
posture and muscle imbalance, which may accentuate
degenerative disease and increase symptoms. However, it
is equally important to recognise that withdrawing from
normal activities of daily life can result in deconditioning
of musculoskeletal structures that may lead to degenera­
tive disease and an increase in symptoms (Waddell 1992;
Frost et al. 1998).
Identify the patient’s hobbies or interests. Is she/he able
to participate in a sport if desired? If not, determine the
reasons. Identify the length of time the patient has been
off work or has been unable to participate in physical
activities. Evaluate the progression of symptoms. If the
person has not been participating in physical activities,
and if no improvement has occurred it may be appropriate
to advise a return to light training in order to prevent
devitalisation of tissues and fear avoidance issues.
Present condition
Area of the symptoms
It is useful to record the area of the pain by using a
body chart, because this affords a quick visual reference
(Maitland 2001). The patient may complain of more than
 Musculoskeletal assessment Chapter 11

Tick the areas of the body

that are asymptomatic

P1 Intermittent
dull ache
↑ sitting 1/2 hour
↓ standing 1/2 hour and
walking 10 minutes

P2 Intermittent
‘electric shock’ pain
P3 Intermittent ↑ sitting and flexion
numbness when ↓ standing and walking
P1 + P2 are severe,
and going from sit to stand

Key
↑ Factor that increases symptoms
↓ Factor that decreases symptoms

Figure 11.1  Typical body chart. In this example the patient’s details have been recorded.

Please mark on this line with a cross how you would rate your pain
Morning After activity

No pain Worst pain

imaginable
Figure 11.2  The visual analogue scale (VAS).

one symptom, so the symptoms may be recorded or re­­ Duration of the symptoms
ferred to individually as P1 and P2 and so on. Areas of
Establish whether the pain and symptoms are intermittent
anaesthesia or paraesthesia may be recorded differently on
or constant. Is the pain present all of the time or does it
the pain chart – they may be represented as areas of dots in
come and go depending on activities or time of day?
order to distinguish them from areas of pain (Figure 11.1).

Aggravating and easing factors

Severity of the symptoms
The severity of the pain may be measured on a visual
analogue scale (VAS) (Figure 11.2) or on a numerical scale
of 0–10 to quantify the pain, where 0 stands for no pain
at all and 10 is perceived by the patient as the worst pain
imaginable. The mark on a VAS can then be measured and
recorded for future comparisons using a ruler. Although
these measures are not wholly objective, they do allow
changes to be monitored as the treatment progresses.
Positional factors
Most musculoskeletal pain is mechanical in origin and is
therefore made better or worse by adopting particular
positions or postures that either stretch or compress the
structure that is giving rise to the pain. Moreover, aggravat­
ing and easing movements may provide the physiothera­
pist with a clue as to the structure that is causing the pain.
Various body or limb positions place different structures

209
 Tidy’s physiotherapy
on stretch or compression and the resultant deformation
produces an increase in severity of the pain. The aggravat­
ing and easing factors can be recorded on the pain chart,
as in Figure 11.1. It is also necessary to record the length
of time that engaging in aggravating activities produces
an increase in symptoms or, alternatively, takes to settle
down. This indicates the irritability of the patient’s
condition.
Time factors
It is useful to record the behaviour of signs and symptoms
over a 24-hour period – the diurnal pattern. Do the symp­
toms keep the patient awake or awaken the person regu­
larly during the night? Is this because of a particular
sleeping posture or to other, unrelated factors? On arising,
how are the symptoms for the first hour or so of the day
and, moreover, do the symptoms vary from the morning
to the afternoon and into the evening? Does this follow a
particular pattern? This information can be included on
the body chart.
Be careful not to confuse time of day with the perform­
ance of particular activities that the patient may undertake
at that time. Certain pathologies tend to be more painful
at characteristic times of the day. For example, chronic
osteoarthritic changes are characteristically painful and
stiff initially on arising from sleep, intervertebral disc
related pain is often more painful on arising owing to the
disc imbibing water during sleep and thus exerting pres­
sure on pain-sensitive structures. Prolonged morning pain
and stiffness, which improves only minimally with move­
ment, suggests an inflammatory process (Magee 1992).
Determining the SIN factors
Once the severity of the symptoms and the aggravating
and easing factors have been noted, it is then possible
to determine the SIN factor of the condition: severity/
irritability/nature. SIN factors are used to guide the length
and firmness of the objective assessment and subsequent
treatment.
Severity
This can be quantified by the VAS, numerical scale or other
valid pain questionnaire. It can be recorded as high (pain
score of around 7–10), moderate (score around 4–6) or
low (score around 1–3).
Irritability
This is the time that the person has to perform the activity
to increase the pain and, conversely, how long it takes
before the pain settles to its former intensity. It can be
measured as either high (the aggravating factor causes the
pain to increase very quickly or instantly and then the pain
210
takes a long time to settle back), moderate (the aggravating
factor takes longer to increase the symptom) or low (the
aggravating factor can be performed for a long time before
exacerbating the patient’s symptoms and then on stopping
the activity the symptoms subside rapidly). An example of
low irritablity would be that the knee pain is aggravated
after jogging for one hour and then subsides after one
minute of rest.
Nature
It is possible to hypothesise the nature of the condition
following the subjective history, i.e. whether the patient’s
condition has a predominantly inflammatory, traumatic,
degenerative or mechanical cause.
History of the present condition
Insidious onset
Insidious onset means that the patient’s symptoms appear
without any obvious cause. An example of this would
be a degenerative condition such as osteoarthritis. These
types of conditions often begin with a small amount of
stiffness and pain, which is characterised by exacerbation
and remission but is, nonetheless, progressive.
Traumatic onset
Can the onset of symptoms be related to a particular
injury? Identify if there was a definite cause for the patient’s
symptoms. The mechanism of injury may be indicative of
the structures damaged. For example, a valgus strain of the
knee may stretch the medial collateral ligament of the
knee, whereas forced rotation of the knee joint when in a
semi-flexed weight-bearing position may tear the menisci.
Progression of the condition
Are the patient’s symptoms getting better or worse? Acute
soft-tissue injuries normally undergo a period of inflam­
mation and repair, and symptoms may subside rapidly
within a few days or weeks. However, progressive arthritic
diseases may have a history of exacerbation and remis­
sions with a general increase in the severity or frequency
of their symptoms, as the disease progresses.
Progression of the condition may indicate how quickly
the patient’s symptoms will subside.
Chronicity or age of the condition
How long has the patient experienced the symptoms? Is
the condition acute or chronic? If the injury is chronic or
has not resolved completely, it may indicate a number of
different causes, such as mechanical instability from a liga­
ment disruption, functional instability because of weak­
ened muscles, loss of proprioception (and therefore the

loss of an inherently protective reflex mechanism at the
joint) or malalignment. Furthermore, it may be develop­
ing into a degenerative condition. The physiotherapist
should identify the following:
1. Is this the first episode?
2. Is it recurrent?
3. Is it getting better or worse?
Previous treatments
Has the patient received any treatment for this condition
in the past and, if so, was it effective? Was the improve­
ment partial or total, and did it provide permanent or
temporary relief? If the treatment has been effective in
the past it may well help again. Be careful not to repeat
unsuccessful interventions as they are unlikely to be
therapeutic.
Investigations
Record the results of any investigations that the patient has
undergone. Case notes, radiographic films and reports can
be ordered and read, as patients may not always be a reli­
able source of the results of their investigations.
X-rays, MRI scans, CAT scans and bone scans
Scans are now commonly used to aid the diagnosis of
musculoskeletal disorders. X-rays are useful in that they
show the degree or extent of arthritis present at a joint.
They are also useful in determining the extent of osteomy­
elitis (bone infection) and some malignancies and oste­
oporosis. Moreover, they are valuable following trauma to
identify fractures or dislocations. Be aware, however, that
there is a poor correlation between X-rays and spinal
symptoms for non-specific low back and neck pain. What
is identified as pathological on these tests may not always
be the structure responsible for the patient’s signs and
symptoms. Routine X-rays are not helpful in non-specific
degenerative spinal disease (CSAG 1994).
Computerised axial tomography (CAT) scans may be
used to identify the precise level and extent of disc pro­
lapse and subsequent nerve impingement prior to discec­
tomy. Magnetic resonance imaging (MRI) may be used to
identify ligamentous and muscular injuries, particularly in
athletes, as well as discogenic prolapse. Bone scans are
sensitive to ‘hot spots’ or areas of inflammation present in
bone and may detect malignancy or diseases such as anky­
losing spondylitis, some fractures and infection sites.
Blood tests
These are used extensively for the confirmation of the diag­
nosis of particular diseases such as rheumatoid arthritis,
ankylosing spondylitis, osteomyelitis and malignancy.
Musculoskeletal assessment Chapter 11
Other investigations
The patient may be undergoing investigations for other
pathologies that could possibly relate to the musculo­
skeletal condition. These should be noted and recorded.
Past medical history
Determine whether or not the patient is suffering, or has
suffered, any major operations or illnesses. These may
affect the vitality of the tissues and be a contraindication to
particular treatments. Examples are respiratory or cardiac
disease, diabetes, rheumatoid arthritis and epilepsy.
The prolonged use of oral steroid medication should
be noted, as this affects bone density and produces a
tendency towards bruising. This is commonly found in
patients suffering chronic respiratory diseases, inflamma­
tory bowel diseases or rheumatoid arthritis. Always
identify cases of unexplained weight loss and general
debility.
Clinical note
Unexplained weight loss, general debility or the patient
looking generally unwell – unremitting pain that is
unrelieved by changing position or medication – may
suggest a non-mechanical basis for the pain. Feeling
unwell or tired is common in neoplastic disease affecting
the spine (O’Conner and Curner 1992). In these cases,
malignant disease should be suspected and the patient
should be referred back immediately to the referring
GP or consultant with a full report of your findings.
Physiotherapy management may well be contraindicated
in this situation and may be wasting valuable time for
the patient.
Medication
Record the type and dosage of medication prescribed for,
or taken by, the patient. Commonly prescribed drugs for
use in musculoskeletal conditions are:
• analgesics (painkillers), e.g. paracetamol and
co-codamol;
• non-steroidal anti-inflammatory drugs (NSAIDs), e.g.
ibuprofen;
• skeletal muscle relaxants, e.g. diazepam and
baclofen.
Medications being taken should alert you to pathologies
that the patient may have forgotten to inform you about.
For example, a person may tell you that she/he has no
significant medical history, but then later in the assess­
ment say that she/he is currently taking anticoagulation
therapy for a recent deep vein thrombosis!
211
 Tidy’s physiotherapy

OBJECTIVE ASSESSMENT
Following the subjective assessment it is important to
highlight the main findings and determine the SIN
factor. A hypothesis may be reached as to the cause of the
patient’s symptoms and the testing procedures are per­
formed in order to support or refute the physiotherapist’s
hypothesis.
General observation
Observe the person’s gait and general demeanour on
entering the department.
Passive movements
These are movements performed by an external source,
such as the physiotherapist or a pulley system. There are
two types of passive movements.
• Physiological movements are movements that could
be performed actively by the patient (e.g. flexion of
the knee or abduction of the shoulder joint).
• Accessory movements cannot be performed actively
by the patient (e.g. they incorporate glide, roll or
spin movements that occur in combination as part
of normal physiological movements). An example of
an accessory movement is an anterior–posterior glide
at the knee joint.

Resisted movements
Local observation
These are performed against the resistance of the physio­
Note any localised swelling at the joint. This may be meas­ therapist or weights by the patient’s own effort.
ured with a tape measure around the joint or limb circum­
ference. Note any asymmetry of joint contours, redness of
the overlying skin suggesting local inflammation, atrophy
and asymmetry of musculature, deformity, and malalign­ Clinical note
ment of the joint or joints. Compare one joint closely with
the other side whenever possible. Passive, active and resisted movements are used in the
assessment and in the treatment of musculoskeletal
disorders. Specific examples of these are included later in
Posture the individual joint assessments formats.
Observe any asymmetry of posture in standing, walking
and sitting. Poor posture is frequently a precursor to
muscle imbalance, selective tightness and weakness
through over- or under-use of specific muscles. The result Assessment of range of movement
of prolonged poor postural habits may lead to an accelera­
tion of certain pathologies such as adhesive capsulitis, Measurement of joint range using
shoulder impingement syndrome, spinal pain and arthri­ a goniometer
tis. Poor posture is frequently the cause of aches and pains Active movement may be assessed by the use of a goniom­
and may be correctable in the early stages and improved eter (Figure 11.3) or, alternatively, by visual estimation. It
in later stages. Correction may prevent recurrence or accel­
eration of specific pathologies.

Palpation
Palpate for the following:
• tenderness;
• heat (use the back of your hand – it is more sensitive
to heat changes);
• swelling;
• muscle spasm.

Assessment of movement
Active movements
These are movements performed by the patient’s voluntary Figure 11.3  Using the goniometer to measure hip joint
muscular effort. medial rotation with the hip in 90 degrees of flexion.

212

is measured in degrees and it is useful to practise using the
goniometer by measuring the hip, knee and ankle joints
in various positions. Either the 360° or 180° universal
goniometers may be used. Ensure adequate stabilisation
of adjacent joints prior to taking the measurements and
locate the appropriate anatomical landmarks as accurately
as possible. For details on specific joint measurements
using the goniometer, refer to the appropriate joint assess­
ment. Physiological and accessory passive movements are
measured in terms of the above and by the end-feel
respectively.
Differentiation tests
If a lesion is situated within a non-contractile structure
such as ligament, then both the active and passive move­
ments will be painful and/or restricted in the same direc­
tion. For example, both the active and passive movement
of inversion will produce pain in the case of a sprained
lateral ankle ligament. However, if a lesion is within a
contractile tissue such as a muscle, then the active and
passive movements will be painful and/or restricted in
opposite directions (Cyriax 1982). For example, a ruptured
quadriceps muscle will be painful on passive knee flexion
(stretch) and resisted knee extension (contraction).
Clinical note
Remember that it is insufficient to measure only the
range of movement occurring. The quality of movement
should also be observed, along with limiting factors to
the movement. Is it the pain, muscle spasm, weakness
or stiffness that is limiting the movement? This is
determined by noting the differences between active,
passive and resisted movements.
End-feel
During passive movements, the end-feel is noted. Differ­
ent joints and different pathologies have different end-
feels. The quality of the resistance felt at the end of range
has been categorised by Cyriax (1982). For example:
• bony block to movement or a hard feel is
characteristic of arthritic joints;
• an empty feel, or no resistance offered at the end of
range, may be a result of severe pain associated with
infection, active inflammation or a tumour;
• a springy block is characterised by a rebound feel at
the end of range and is associated with a torn
meniscus blocking knee extension;
• spasm is experienced as a sudden, relatively hard feel
associated with muscle guarding;
• a capsular feel shows a hardish arrest of movement.
Musculoskeletal assessment Chapter 11
Assessment of muscle strength
Symptoms arising from resisted contractions
The Oxford scale is relatively quick and easy to use, and is
used widely in clinical practice. However, it is not very
objective, functional or sensitive to change as the move­
ments resisted are concentric contractions and the spaces
between the grades are not linear. Nevertheless, it provides
a guide to muscle strength and is somewhat sensitive to
change.
The Oxford classification
0 = no contraction at all
1 = flicker of contraction only, movement of the joint
does not occur
2 = movement is possible only with gravity
counterbalanced
3 = movement against gravity is possible
4 = movement against resistance is possible
5 = normal functional movement is possible
Measurements using isokinetic machines
Objective measurements of strength throughout different
joint angles and at different velocities are made more
accurately using isokinetic machines, such as Cybex or
Kin-Kom. These machines are particularly valuable in
rehabilitative regimens such as anterior cruciate rehabilita­
tion programmes and can determine the strength ratio of
the quadriceps to the hamstrings, or the ratios of the oper­
ated versus the non-operated leg. Objective markers such
as percentages of strength ratios or ratios of operated
versus non-operated leg may be used in setting discharge
protocols. Isokinetic machines have been found to be reli­
able and valid in measuring muscle torque, muscle veloc­
ity and the angular position of joints (Mayhew et al.
1994). However, they are limited in their use, and Wojtys
et al. (1996) suggest that agility and functional exercises
may be more beneficial than isokinetic machines in the
strengthening of muscle.
Clinical note
Tests of specific structures are performed in order to
reproduce the patient’s symptoms or signs, i.e. to
reproduce the comparable sign. Differentiation tests are
useful to distinguish between two or more structures
that are suspected to be the source of the symptoms.
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 Tidy’s physiotherapy
Differentiation tests of muscles   Active insufficiency of muscles
and tendons
These are contractile structures and are therefore tested
by performing a contraction against resistance. A pain
response and/or apparent weakness may indicate a strain
of the muscle at any particular point of the range of move­
ment. Full range should be checked as the muscle may be
weak only at a particular point in the range. Muscle length
may also be tested, particularly those muscles that are
prone to become tight and then lose their extensibility.
Muscles that pass over two joints and have mobiliser char­
acteristics are particularly prone to tightness. Examples of
these are the hamstrings, rectus femoris, gastrocnemius
and psoas major. The length of the muscle is tested by
passively moving the appropriate joints. The stretch is
compared with the other side to determine reproduction
of pain and/or restriction of movement.
Passive insufficiency of muscles
This occurs with muscles that act over two joints (Figure
11.4a). The muscle cannot stretch maximally across both
joints at the same time. For example, the hamstrings may
limit the flexion of the hip when the knee joint is in exten­
sion as they are maximally stretched in this position.
However, if the knee is flexed passively, then the hip will
be able to flex further as the stretch on the hamstrings has
been reduced.
A locks and is unable to actively or passively release itself
B periods of relapses and remissions;
Figure 11.4  (a) Passive insufficiency: the muscle cannot
simultaneously stretch maximally across two joints. (b) Active
insufficiency. The muscle cannot simultaneously contract
maximally across two joints.
214
This, too, occurs with muscles that act over two joints
(Figure 11.4b). The muscle cannot contract maximally
across both joints at the same time. An example is the
finger flexors. If you are to make a strong fist, you may
notice that the wrist is in a neutral or an extended position
when you do this action. Now, if you attempt to actively
flex your wrist joint whilst keeping your fingers flexed, you
will find that the strength of the grip is greatly diminished.
This is because the wrist and finger flexors are unable to
shorten any further and so the fingers begin to extend or
lose grip strength.
Differentiation tests of ligaments
Ligaments are non-contractile structures and are tested by
putting the structure on stretch. Examples are a valgus
strain of the knee to stretch the medial collateral ligament
of the knee or passive inversion of the subtalar joint to
stretch the lateral ligament of the ankle. A positive test
would be a pain response or observation or feel of any
excessive movement of the joint when compared with the
other side.
Differentiation tests of bursae
Bursae are sacs of synovial fluid. Inflammation of these
(bursitis) results in tenderness and/or heat on palpation.
The tenderness is often very localised to the site of the
inflamed bursa.
Differentiation tests of menisci
The history and mechanism of injury combined with ante­
rior joint tenderness and the inability to passively hyper­
extend the knee are useful diagnostic markers of meniscal
injury. Rotation on a semi-flexed weight-bearing knee is a
common cause of injury.
A history of locking, whereby the joint momentarily
from the position, is also common. Objectively, the knee
joint is unable to fully flex/hyperextend passively.
Characteristics of degenerative joint disease
Signs and symptoms may include:
• pain that increases on weight-bearing activities
(standing and walking, walking downstairs
particularly);
• insidious onset of symptoms followed by progressive
• pain and stiffness in the morning;
• stiffness following periods of inactivity;
• pain and stiffness that arise after unaccustomed
periods of activity;
 Musculoskeletal assessment Chapter 11

• bony deformity (e.g. characteristic varus deformity
may follow from collapse of the medial
compartmental joint space);
• reduction of the joint space observed on X-ray, with
bony outgrowths or osteophytes.
Writing up the assessment
It is imperative to record the assessment immediately fol­
lowing the physical testing. Patient notes should be com­
pleted on the day of the assessment for legal reasons.
Ensure that your assessment findings are clear and
concise, and that they highlight the main points (it may
be useful to include one subjective and one objective
marker). Formulate a problem list in agreement with the
patient. Agree and record SMART goals (specific, measur­
able, achievable, realistic, timed) with the patient. Use the
problem-orientated medical records (POMR) system.
Remember, if you have insufficient time to conduct a
full and thorough assessment you can always continue
with this when the patient attends for his/her subsequent
appointment.

Spinal assessments

(lateral curvature) or shift (lateral deviation). Laterally,

THE LUMBAR SPINE
Posture
Normal alignment
Posteriorly, the shoulders, waist creases, posterior superior
iliac spines, gluteal creases and knee creases should be
horizontal (Figure 11.5). The spine should appear to be
vertical. There should be no rotation, side flexion, scoliosis
you should observe a normal lordosis in the lumbar spine.
Anteriorly, the anterior superior iliac spines should be
horizontal.
Common deviations from normal posture
(refer to Figure 11.6)
• Creases in the posterior aspect of the trunk and,
particularly, adjacent to the spine may indicate areas

Posterior view Surface marking points to note Lateral view Points to note

Ears level Through ear lobe

Neck lines symmetrical
Shoulders level
Inferior angles of scapula level Through shoulder joint
Position of arms relative to body
Position of spine straight
Waist contours symmetrical
Position of iliac crests level
Through greater trochanter
Buttock fold level

Knee creases symmetrical Anterior to knee joint

Anterior to lateral malleolus

Tendo calcaneus straight

Position of line of gravity

Figure 11.5  Examination of the spine.

215
 Tidy’s physiotherapy
Normal Lordosis Kyphosis
Figure 11.6  Abnormal postural curves of the spine.
of hypermobility or instability of that motion
segment.
• Sway back comprises hyperextension of the hips, an
anterior pelvic tilt and anterior displacement of the
pelvis.
• Flat back consists of a posterior pelvic tilt
and a flattening of the lumbar lordosis, extension
of the hip joints, flexion of the upper thoracic
spine and straightening of the lower thoracic
spine.
• Kypholordosis consists of a forward-poking chin
posture, elevation and protraction of the shoulders,
rotation and abduction of the scapulae, an increased
thoracic kyphosis, anterior rotation of the pelvis and
an increased lumbar lordosis.
• Shifted posture (lateral shift) commonly arises from
disc herniation or acute irritation of a facet joint.
The shift is thought to result from the body finding a
position of ease whereby the shoulders are displaced
laterally in relation to the pelvis. Most commonly
the shift occurs away from the painful side
(Figure 11.7).
216
Flat back Sway back
Movements
Assess not only the range of movement occurring and the
pain response, but also localised areas of give and restric­
tion occurring at specific motion segments.
Active movements
Flexion
Flexion should result in a smooth curve. Segmental areas
of give or restriction appear as hinging (segmental
hypermobility). Lack of movement in the lumbar spine
may be compensated by flexion at the hips or thoracic
spine flexion. The gross movement may be measured as
fingertip-to-floor distance with a tape measure. Note
any limitation of movement, lateral deviation and pain
response (Figure 11.8).
Extension
Observe extension in relation to areas of give or restriction.
Observe for hinging at specific motion segments indicat­
ing areas of hypermobility. This may appear as horizontal

Figure 11.7  Lateral shift.
lines appearing across the hypermobile segment. Note any
limitation of movement and pain response.
Side flexion (Figure 11.9)
Normal movement should be observed as a smooth curve.
Areas of give or restriction will be observed as hinging
(segments of hypermobility) or plane lines (areas of hypo­
mobility). Compare with the other side for symmetry.
Note any ‘coupling’ of movements, i.e. the trunk may flex
or rotate to compensate for restriction of side flexion.
Passive physiological intervertebral
movements (PPIVMs)
These can be used to confirm any restriction of motion
seen on active movement tests and to detect restriction of
movement not discovered by the active movement tests.
PPIVMs also detect segmental hypermobility (Magarey
1988; Maitland 2001).
Overpressure
If the plane movements have full range and are pain-free,
then overpressure applied slowly and with care can be
Musculoskeletal assessment Chapter 11
Figure 11.8  A faulty lumbar flexion pattern. All movements
occur at the hip joint while the lumbar spine remains in an
extended position.
administered. At the end of the available range the physi­
otherapist may apply a small oscillatory movement to
assess the quality and end-feel of the movement. Also, the
range of further movement should be noted, as well as the
pain response.
Repeated movements
Repeating movements several times may alter the quality
and range of the movement and may give rise to latent
pain. McKenzie (1981) advocates the use of repeating
flexion and extension in both standing and lying to deter­
mine the movement that may centralise the patient’s
symptoms (Figure 11.10). According to Palmer and Epler
(1998), progressive worsening of pain on repeated move­
ments indicates a disc derangement – the pain either
becoming more intense or spreading more distally. Cen­
tralisation of symptoms means that the referred pain
becomes more proximal, i.e. pain experienced at the
medial aspect of the shin may centralise to the buttock.
Thus, the exercise is believed to be reducing the patient’s
symptoms and the disc derangement.
Combined movements
According to Edwards (1992): ‘Although the use of com­
bining movements is not always necessary – adequate
217
 Tidy’s physiotherapy
A B
Figure 11.9  Side flexion (a) to the right, and (b) to the left. Note the difference, and the pain response.
Figure 11.10  Repeated extension in prone.
results being obtained by standard examination proce­
dures – there are times when they are helpful. Often, with
the more difficult mechanical problems, their use is
essential.’
For example, lumbar spine extension may be performed
and, while maintaining that extension, side flexion may
218
be added. Symptoms are likely to vary with the addition
of a second movement and this may indicate whether or
not there is a regular or irregular stretch component to the
signs and symptoms. For example, if a disc prolapse is
aggravated by flexion, it would be reasonable to hypoth­
esise that the addition of contralateral side flexion would
also further increase the symptoms because both of the
movements are stretching the posterior component of the
disc and posterior longitudinal ligament. Combining ipsi­
lateral side flexion to flexion would be expected to lead to
a reduction in the patient’s symptoms as the ipsilateral
side flexion is reducing the stretch component.
Differentiation between the hip and lumbar
spine as a source of symptoms
The hip joint may give rise to pain in the buttock or groin.
In order to differentiate between pain arising as a result of
spinal or hip pathology it is important that the therapist
discounts the hip joint as a possible source of symptoms.
With the patient supine, full flexion, medial and lateral
rotation is performed actively and passively at the hip

Figure 11.11  Compression testing of the posterior sacroiliac
ligaments.
joint. These are the movements commonly painful or
restricted by degenerative joint conditions such as osteoar­
thritis. If these movements are pain-free and full-range
then it is unlikely that the hip is a source of symptoms.
Compare both sides.
Assessing the sacroiliac joint
Sitting flexion (Piedello’s sign)
The seated patient is asked to flex forwards. The physio­
therapist palpates the sacral dimples bilaterally. Both
sacral dimples should move equally in a cephalad direction
(i.e. towards the head). (This tests the movement of the
sacrum on the ilium.) Excessive rising of one side indicates
hypomobility at that sacroiliac joint.
Standing flexion (stork test)
With the patient standing, the physiotherapist locates the
sacral dimples (level of S2) and places the other hand
centrally at the sacrum. The patient is instructed to stand
on one leg while flexing the non-weight-bearing hip and
knee. The sacral dimple on the non-weight-bearing side
should appear to move caudally (towards the floor) by
approximately 1 cm as the ilium rotates posteriorly. Hypo­
mobility is observed if the dimple does not move distally
in relation to the sacrum.
Compression tests
Posterior ligaments
These test the integrity of the posterior sacroiliac ligaments.
The patient lies supine and the hip is passively flexed
towards the ipsilateral shoulder (Figure 11.11). A down­
ward thrust is applied along the line of the femur. Observe
for pain response, clunk and difference in end-feel between
both sides. The test is repeated for (oblique) hip flexion
towards the contralateral shoulder and (transverse) hip
flexion towards the contralateral hip.
Musculoskeletal assessment Chapter 11
Figure 11.12  The Faber or four test. Normal range of
movement.
Anterior ligaments – Faber test
Flexion plus abduction plus external rotation (the ‘Faber’
test) tests the integrity of the anterior sacroiliac ligaments.
The test is also described as the ‘four test’ because of the
position of the patient’s limb, a combination of flexion,
abduction and external rotation. The physiotherapist
pushes the leg downward, just proximal to the knee joint
while stabilising the opposite hip with the other hand. A
normal finding would be to lower the leg to the level of
the opposite leg. Observe for pain response or limitation
of movement (Figure 11.12).
Neurological testing
Compression or traction of spinal nerve roots by disc
trespass and/or osteophytes may give rise to referred
pain, paraesthesia and anaesthesia, and also give positive
neurological signs. Neurological signs should be carefully
monitored as deterioration may indicate worsening
pathology.
Dermatomes
A dermatome is an area of skin supplied by a particular
spinal nerve. Dermatomes may exhibit sensory changes for
light touch and pin prick. Test each dermatome individu­
ally, on the unaffected and then the affected side.
Myotomes
A myotome is a muscle supplied by a particular nerve root
level. These are assessed by performing isometric resisted
tests of the myotomes L1–S1 in middle range, held for
approximately three seconds. Test the unaffected side, then
the affected: LI–L2 for the hip flexors (see Figure 11.13),
L3–L4 for knee extensors (see Figure 11.14), L4 for foot
dorsiflexors and invertors, L5 for extension of the big toe,
S1 for plantar flexion (see Figure 11.15) and knee flexion,
S2 for knee flexion and toe standing, and S3–S4 for
muscles of the pelvic floor and the bladder.
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 Tidy’s physiotherapy

Figure 11.13  Resisted hip flexion to test myotome L1/2.

Figure 11.14  Resisted knee extension to test myotome L3.

Reflexes
• Test the non-affected first then affected side. Note:
dull reflexes may indicate lower motor neurone
dysfunction. Brisk reflexes may indicate an upper
motor neurone dysfunction.
• L3 corresponds to the quadriceps. The patient sits
with the knee flexed and the therapist hits the
patellar tendon just below the patella (Figure 11.16).
• S1 corresponds to the plantarflexors. Dorsiflex the
ankle and strike the Achilles tendon. Observe and
feel for plantar flexion at the ankle (Figure 11.17).

Clinical note

The Babinski reflex (or plantar response) is an abnormal

response and occurs when a blunt object is drawn up
the lateral aspect of the sole of the foot. Normally, the
great toe (big toe) flexes. Abnormally, the great toe
extends indicating upper motor neurone damage. Note
that this primitive reflex is seen in the newborn but
disappears with time.

Adverse mechanical tension

Passive neck flexion
The patient is supine. The physiotherapist flexes the
patient’s neck passively. Observe for any low back pain
response, which may suggest disc pathology.

Straight leg raise (SLR) Figure 11.15  Toe standing (plantar flexion) to test myotome
This is also known as Lasegue’s test. The patient is supine. S1.
The physiotherapist lifts the patient’s leg while maintain­
ing extension of the knee (Figure 11.18). An abnormal

220

Figure 11.16  The quadriceps reflex (L2, L3, L4).
Figure 11.17  The Achilles tendon reflex (S1, S2).
Musculoskeletal assessment Chapter 11
Figure 11.18  SLR test adding dorsiflexion of the ankle joint.
Figure 11.19  Femoral nerve test.
finding is back pain or sciatic pain. The sciatic nerve is on
full stretch at approximately 70 degrees of flexion, so a
positive sign of sciatic nerve involvement occurs before
this point (Palmer and Epler 1998). Any pain response
and range of movement is noted and comparison made
with the other side. Factors such as hip adduction and
medial rotation further sensitise the sciatic nerve; dorsi­
flexion of the ankle will sensitise the tibial portion of the
sciatic nerve; plantar flexion and inversion will sensitise
the peroneal portion of the nerve.
Prone knee bend (femoral nerve stretch)
The patient lies prone and the physiotherapist flexes the
person’s knee and then extends the hip (Figure 11.19).
Pain in the back or distribution of the femoral nerve indi­
cates femoral nerve irritation or reduced mobility. Com­
parison is made with the other side.
221
 Tidy’s physiotherapy
Slump test
This tests the mobility of the dura mater. The patient sits
with thighs fully supported with hands clasped behind the
back. The patient is instructed to slump the shoulders
towards the groin (Figure 11.20). The physiotherapist
applies gentle overpressure to this trunk flexion. The
patient adds cervical flexion, which is maintained by the
therapist. The patient then performs unilateral active knee
extension and active ankle dorsiflexion. The physiothera­
pist should not force the movement. The non-affected side
should be assessed first.
Any symptoms are noted at the particular part in range.
If the dura mater is tethered, symptoms will increase as
each component is added to the slump test. The patient is
instructed to extend the head – a reduction in symptoms
on cervical extension is a positive finding, indicating
abnormal neurodynamics.
Testing for lumbopelvic stability
Stability of the lumbar spine is necessary to protect the
lumbopelvic region from the everyday demands of posture
and load changes (Panjabi 1992). It is essential for pain-
free normal activity (Jull et al. 1993) and should always
be assessed.
With the patient in crook lying with the hips at 45
degrees flexion, he/she is instructed to maintain a neutral
Figure 11.20  Slump test with single knee extension.
222
spine (it may be useful to tell the patient to maintain such
a lordosis that an army of ants could just crawl through!).
The person then performs an abdominal in-drawing by
contracting the transversus abdominis muscle while
attempting to maintain the spine in neutral. To challenge
the transversus abdominis and multifidus stabilising
muscles (and consequently the spinal position), the
patient adds the leg load by alternately lifting the heels
from the floor and sliding out the leg while maintaining
a neutral spine position. The maintenance of a neutral
spine posture can be assessed by using a biofeedback
device. An inability to maintain the spine in neutral will
result in the lumbar spine extending as the leg is lifted.
The intra-abdominal pressure mechanism is controlled
primarily by the diaphragm and transversus abdominis
which provides a stiffening effect on the lumbar spine
(Hodges and Richardson 1997).
Palpation
Soft-tissue thickening over the articular pillar at one or
more spinal levels is a common finding in cases of degen­
erative disease of the lumbar spine, as is hard bony thick­
ening and prominence over the apophyseal joints. Note
any general tightness or localised thickening of muscular
tissue or ligamentous tissue. In general, the older the soft-
tissue changes, the tougher they are; the more recent, the
softer they are. However, a thickened or stiff area is not
necessarily painful or the source of a patient’s symptoms
(Maitland 2001).
Accessory spinal movements
The physiotherapist applies central posteroanterior
pressures on the spinous processes and unilateral (one-
sided) pressure over the articular pillar (Figure 11.21),
noting areas of hyper- and hypomobility. Record any
Figure 11.21  Unilateral pressures applied to the lumbar
spine over the articular pillar. Note the pressure is applied
through the physiotherapist’s pisiform bone.

pain experienced by the patient and the corresponding
spinal level.
Biopsychosocial assessment  
(lumbar spine)
Although historically there has been no change in the
pathology or prevalence of low back pain (LBP), disability
owing to non-specific LBP has increased dramatically in
modern Western societies. Medical interventions for
chronic LBP using a limited biomedical approach have
been relatively unsuccessful and the cost to National
Health Service (NHS) physiotherapy services has been
estimated to be £151 million per annum (Maniadakis
and Gray 2000). LBP has been described as a twentieth-
century healthcare disaster (Waddell 1992). In 80% of
cases of LBP no significant pathology is ever found, despite
CASE STUDY
LUMBAR SPINE
A 30-year-old labourer was referred for physiotherapy
following a lifting injury at work. He complained of
left-sided low back and medial shin pain, and
intermittent paraesthesia affecting his left great toe. The
pain was aggravated by flexion and eased by standing
and walking. On examination he had a marked shift to
the right. Flexion was reduced to fingertips to knees and
his left SLR was reduced to 50 degrees.
Owing to the rapid onset of symptoms associated
with a lifting injury in a flexed posture, and the pain
being aggravated by flexion and eased by extension
activities, the injury was hypothesised to be discogenic.
Clinical trials suggest that the most usual sources of low
back pain are the intervertebral disc, the zygapophyseal
(facet) joint and the sacroiliac joint (Maitland 2001).
The patient was treated by rotations to the right (as
demonstrated on another patient in Figure 11.22), which
centralised his pain. His shift was manually corrected on
the first visit. He was prescribed repeated extension
exercises in prone, as advocated by McKenzie (1985), to
do at home every two hours. By the third visit his pain
had centralised to left low back pain and his SLR was 80
degrees. He was then treated by unilateral mobilisations
on the left at grade 4. This alleviated his symptoms and
he regained full range of all movements.
Prior to discharge, he was given a programme of
abdominal and multifidus exercises. He was also given
postural and ergonomic advice prior to his return to
work. The multifidus and the transverse abdominus
muscles have been found to be primarily responsible for
imparting local stability to the lumbar spine in the joint’s
neutral zone (Panjabi 1992; Goel et al. 1993; Wilke et al.
1995; Hodges and Richardson 1996).
Musculoskeletal assessment Chapter 11
Figure 11.22  Right-sided lumbar rotation, used to treat
left-sided back and leg pain.
considerable disability. Recent guidelines based on sys­
tematic reviews of contemporary literature have recom­
mended a biopsychosocial approach in the assessment
and treatment of LBP (CSAG 1994; RCGP 1999; NICE
2009).
Fundamental differences between acute
and chronic pain
It is not satisfactory to view chronic pain simply as acute
pain that has persisted for a long period. Acute and chronic
pain are different clinical entities. We now acknowledge
that there are many different mechanisms and processes
involved in the genesis of chronic pain states which are
not relevant in acute pain. The diversity of these elements
has led to the use of a biopsychosocial approach to indi­
cate that there are biological, social and psychological
factors relevant within an individual that can be either
causing or maintaining the chronic pain state
Acute pain is basically a protective mechanism to reduce
the possibility of increasing the injury. It is usually self-
limiting, and lasts until the tissues are healed. It is usually
associated with an increased sympathetic nervous activity.
This may be associated with feelings of anxiety, panic,
nausea, etc. and may be observed during traumatic injuries
to the bones and soft tissues.
Chronic pain is detrimental because it lasts long after the
injury has healed. Tonic self-sustaining neural loops are
set up to perpetuate the pain. Decreases in sympathetic
activity may cause depression and apathy. Chronic pain
outlasts the normal time of healing and has no recognis­
able end-point (Grichnik and Ferrante 1991).
Predictors of chronic incapacity
Can disability from low back pain be predicted? Psycho­
social researchers in the last decade have found common
psychosocial and social traits in people who have devel­
oped chronic disability owing to LBP. Many subjects with
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 Tidy’s physiotherapy
chronic LBP have been reported to have a psychological
profile that predisposes them to develop chronic pain
(Burton et al. 1995; Carrageen 2001). Additionally, people
aged between 50 and 60 years are more likely to become
disabled because of LBP (Burton et al. 1995).
Further major predictors are listed here.
• People who have unrealistic beliefs about their pain
and the nature of their disease (Waddell 1992).
• People whose occupation involves heavy manual
work and sustained postures.
• People with a previous history of sickness absence.
• People who seek multiple investigations and
treatments (Waddell 1992; Harding and Watson
2000).
• People with low educational achievement or
low-status occupations (Cats-Baril and Frymoyer
1991; Frymoyer 1992).
• People who have pending compensation issues
(Tait and Chibnall 2001).
• People with fear-avoidance beliefs, that a fear of
activity may be more disabling than the original
injury (Vlaeyen 1995; Fritz et al. 2001).
• People who exhibit ‘illness behaviour’, which may
include attention seeking, grimacing, catastrophising
about their problems or LBP, inappropriate coping
strategies, excessive use of splints, braces, walking
aids, over-reliance on the NHS, and passive rather
than active treatment modalities.
In view of the above factors, it is necessary to screen
patients with LBP in order to attempt to reduce the likeli­
hood of chronic disability. It is important to note that a
patient’s general physical fitness may be a poor predictor
of chronic incapacity (Deyo and Weinstein 2001). The
identification of the patients at risk of progression to chro­
nicity (failure to respond to treatment) is by means of
psychosocial questionnaires, because clinical variables
contribute practically nothing to our predictive ability
(Burton et al. 1995). The psychosocial traits concerned
(coping strategies, depressive tendencies, inappropriate
beliefs about pain and activity) are present in the acute
phase – they are not just the result of persistent symptoms
(Burton et al. 1995).
Management guidelines for LBP
(CSAG 1994; RCGP 1999)
In the early management of acute LBP, analgesia with
NSAIDs should be administered immediately following
an acute onset. Manipulative therapy is advised in the
early stages, and active exercise and physical activity
should be encouraged. Bed rest is ineffective as treatment
for back pain, but is acceptable in moderation in the acute
situation for 1–2 days.
Encourage physical activity and an early return to
work and sport whenever possible. Practise psychosocial
224
management: educate the patient about the importance of
good postural habits and activities of daily living. Chal­
lenge the patient who has unrealistic beliefs about the LBP
condition and prognosis.
Biopsychosocial assessment
The biopsychosocial assessment differs from the physical
assessment in that it incorporates psychological and social
issues in more depth. This gives the physiotherapist a good
overview of the patient’s circumstances, his or her overall
mood state, beliefs, attributes and thoughts about the
problem, about therapy and about the future.
Psychological factors
A previous history of anxiety and depression, general atti­
tudes and expectations is noted. The patient’s perceived
level of control over the pain is also assessed with particu­
lar regard to the use of active or passive coping strategies
(these are often referred to as ‘internalised’ or ‘externalised’
locus of control).
Social factors
Identify social areas, including work issues, pending com­
pensation, a history of injury, sickness benefits, and daily
functioning, as these may affect the outcome.
Physical examination
A body chart and physical examination may or may not
be conducted, as the physiotherapist deems necessary.
However, if red flags are noted then a neurological exami­
nation is indicated. Assessments may include functional
tests such as:
• the distance that can be walked in five minutes;
• the number of times the person can stand from
sitting in one minute;
• the number of times the person can step up and
down in one minute.
Flags
‘Yellow flags’ are psychosocial factors that include a
previous history of anxiety and depression, impending
compensation, absence from work, sickness benefit,
invalidity benefit, passivity, and high levels of dependency
and poor coping skills. ‘Red flags’ are clinical features
that should alert the therapist to the possibility of severe
pathology. They include bladder and bowel malfunction,
saddle anaesthesia, bilateral paraesthesia, neurological
signs, unexplained weight loss, a past history of
carcinoma, general debility and fever.

Outcome measures questionnaires
The following questionnaires and tools are validated, reli­
able and sensitive. They can be used prior to, and follow­
ing, intervention to determine efficacy.
• The Oswestry Disability Index (Fairbank et al. 1980).
• The VAS.
• The Present Pain Index.
• The short-form McGill Pain Questionnaire (Melzack
1987).
• The Hospital Anxiety and Depression Questionnaire
(Zigmond and Snaith 1983).
• The locus of control questionnaire (FABQ).
Treatment of biopsychosocial aspects
of LBP disability
Many studies have reported decreases in pain levels
and disability following intensive back rehabilitation pro­
grammes combining exercise and cognitive therapy (e.g.
Frost et al. 1998; Guzman et al. 2001). The aims of chronic
spinal rehabilitation programmes are to:
• reduce the patient’s pain, if possible, or enable the
patient to cope more effectively with the pain;
• reduce the patient’s disability;
• encourage, when possible, a return to work and
hobbies to promote better physical functioning (by
challenging the unhelpful belief that pain always
equates to harm);
• encourage an active, patient-centred approach to LBP
management.
Van Korff and Saunders (1996), in a survey of LBP suf­
ferers in the USA, found that patients wanted to under­
stand the following four things.
1. The likely course of their back problem.
2. How to manage the pain.
3. How to return to normal activities of daily living.
4. How to minimise recurrences of back pain.
Example of the content of a back
rehabilitation programme
• Pre-intervention questionnaire and physical tests for
outcome measures.
• Circuit training, including aerobic and strengthening
regimes, with emphasis on postural control, spinal
stability, back extensors and deep abdominal
musculature.
• Patient-centred discussions, seminars on anatomy,
pathology, medication, self help measures, posture
and exercise, etc.
• Relaxation workshops.
• Post-programme questionnaire and physical tests.
• Follow-up questionnaires at 1 and 12 months to
determine how they are managing their LBP.
Musculoskeletal assessment Chapter 11
THE CERVICAL SPINE
Following on from the subjective assessment, the phys­
iotherapist should highlight the main findings and for­
mulate a hypothesis regarding the clinical diagnosis. The
SIN factors will determine the vigour of the examination.
The physiotherapist will attempt to find the patient’s
comparable sign by means of movement or palpation.
Clinical note
Patients presenting with disorders of the cervical spine
may also complain of headaches, dizziness, nausea and
vertigo. Record this in your assessment. These may be
symptoms of vertebrobasilar insufficiency (VBI).
Posture
Note the symmetry of the head on the neck, and the neck
relative to the thorax. The chin should be at 90 degrees to
the anterior aspect of the neck. There should be no obvious
horizontal skin creases posteriorly. A plumbline from the
tragus of the ear should fall behind the clavicle.
Assess the cervical lordosis. A decreased lordosis predis­
poses the vertebral bodies and discs to bear more weight.
An increased lordosis increases the compressive loads on
the zygapophyseal (facet) joints and posterior elements.
Observe for muscle hypertrophy, hypotrophy, spasm,
tightness or general asymmetry.
An acute wry neck (torticollis) presents as a combina­
tion of flexion and rotation or side flexion away from the
painful side. Patients with chronic pathology often have a
poking chin posture which consists of excessive upper and
middle cervical extension and lower cervical/cervicotho­
racic flexion. This results from a weakness of the deep
cervical flexors and overactivity of sternocleido-mastoid
and levator scapulae muscles (Figure 11.23).
Note that cervical posture is influenced by lumbar
posture and, hence, the poking chin posture is exaggerated
by lumbar and thoracic flexion (Figure 11.23). Cervical
and shoulder posture should, therefore, be viewed in both
the sitting and standing postures.
The shoulders should, ideally, be level, but this is often
not the case because of handedness. For example, in a
right-handed person the right shoulder is often held
slightly lower than the left.
Movements
It is important to not only assess the range of movement
occurring in the cervical region but also the quality of that
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 Tidy’s physiotherapy
A B
Figure 11.23  (a) Poking-chin posture, exaggerated by thoracic and lumbar flexion. (b) Correction of cervical posture by
maintaining the lumbar spine in a neutral position.
movement. Note, in particular, the motion segments
where the movement is occurring. Hinging may be
observed, which indicates areas of hypermobility or insta­
bility. Conversely, areas of hypomobility or stiffness are
observed as areas of plane or straight lines.
Key point
For consistency and reliability of reassessment, the same
order of active movements should be carried out each
time.
Active movements
Flexion
The movement should be performed to either the patient’s
pain or the limit of movement. During flexion the cervical
226
lordosis should be obliterated and the spine appears to be
flexed or neutral. The spinous process of C7 should be the
most prominent – C6 and T1 less so. The chin should
approximate the chest. Common faulty patterns are the
upper cervical spine remaining in extension or chin poke.
Loss of range, areas of give and restriction should be
noted, as well as the pain response, muscle spasm and
crepitus.
Extension
The entire cervical spine should extend, and the face
should be almost parallel to the ceiling. A vertical line
should be observed from the chin to sternum. Common
faulty movement patterns include a loss of lower cervical
extension and the head does not move posteriorly to the
shoulders. Furthermore, excessive hyperextension of the
upper and mid cervical spine may occur earlier on in
the movement and the chin pokes forward.

A B
Figure 11.24  (a) Normal right cervical rotation. (b) Faulty position: right side flexion limited and completed with contralateral
rotation. (c) Faulty position: extension with chin poke, upper cervical extension, lower cervical spine remaining flexed.
Side flexion
Often this movement is the most restricted in degenera­
tive spinal pathologies. Tightness in the contralateral ster­
nocleidomastoid and trapezius may be observed. Common
faulty patterns include coupling with rotation owing to
tightness in anterior flexor musculature. Observe range,
pain response and areas of give or restriction. Compare
the sides for symmetry.
Right and left rotation
Observe the range of movement available and the patient’s
pain response, muscle spasm and crepitus. Common
faulty patterns include coupled movements with side
flexion and the eyes not moving in a purely horizontal
plane (Figure 11.24). Compare the right and the left
sides.
Overpressures repeated and combined
movements
If the plane movements are full range and pain-free, then
overpressure may be applied. At the end of the available
range the physiotherapist may apply a small oscillatory
movement to feel the quality and end-feel of the move­
ment, and the range of further movement. The pain
response is also noted. Combined movements may be
examined in an attempt to reproduce the patient’s pain or
restriction of movement. The patient should if possible
perform repeated movements, as this may alter the quality
and range of the movement and may give rise to latent
pain (McKenzie 1990).
The shoulder complex
Observe full shoulder elevation through flexion and
abduction for the shoulders bilaterally, because during the
last few degrees of elevation the thoracic spine extends to
Musculoskeletal assessment Chapter 11
C
allow for full shoulder elevation. A stiff kyphotic thoracic
spine will limit shoulder elevation.
Passive physiological intervertebral
movements (PPIVMs)
PPIVMs may be used to confirm any restriction of motion
seen on active movement and to detect restriction of
movement not discovered by the active movements. They
are also used to detect segmental hypermobility (Magarey
1988; Maitland 2001).
Vertebral artery testing
See the online version of the textbook for a detailed
account of how to perform these tests.
Key point
Vertebrobasilar insufficiency (VBI) is a contraindication to
cervical manipulation and high–grade mobilisations,
particularly rotations, extensions or longitudinal
distractions and traction.
Differentiation test to determine between
vestibular and VBI symptoms
The patient stands and rotates the cervical spine to
the right and left. A note is taken of symptoms such
as dizziness or nausea. Either vertebrobasilar artery
insufficiency or the vestibular apparatus could cause
symptoms produced as a result of this manoeuvre. In
order to differentiate between these two structures, the
physiotherapist fixes the patient’s head and the patient
keeps the feet static and facing forwards. The patient
then rotates his or her body to the right and to the
left while maintaining the head in a static position.
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 Tidy’s physiotherapy

If symptoms such as dizziness or light-headedness are

produced with this manoeuvre then they are a result of
vertebrobasilar pathology, because the head remains still
(and the vestibular apparatus will be unaffected) and the
cervical spine is rotating affecting the artery.

Vertebrobasilar testing (Maitland 2001)

This test is performed in both sitting and supine
positions.
1. Sustained rotation for ten seconds is performed to
each side. Note any symptoms. A
2. Sustained extension for ten seconds is performed. If
the patient is asymptomatic then:
3. Combined rotation and extension to each side is
sustained for ten seconds. Note any symptoms. A
positive test would be to induce feelings of dizziness
and nausea.

Key point

If the patient has grossly restricted range of movement

then the test for VBI is not valid.

Neurological testing Figure 11.25  (a) Resisted shoulder abduction (C5) myotome.
(b) Assessment of C6 myotome in resisted biceps.
Dermatomes
Test for normal sensation, the cutaneous area supplied by
a single posterior root of each spinal segment, light touch
with the dorsal aspect of the hand or cotton wool and
pinprick sensation for each dermatome, C1 to T1.

Myotomes
Isometric testing of the muscles supplied by a spinal
segment in mid range for a few seconds is performed at
each level from C1 to T1 (Figure 11.25). Weakness may
indicate a lower motor lesion from a prolapsed disc or
another space-occupying lesion.

Reflexes
Test for normal reflexes: biceps (C5–C6), triceps and bra­
chioradialis (C7). Compare one side with the other. Note
brisk reflexes which may be indicative of an upper motor
neurone lesion and dull reflexes which may be indicative
of a lower motor neurone lesion.
• C5–C6 correspond to biceps brachii. The person’s
arm should be semi-flexed at the elbow with the
forearm pronated. Place your thumb or finger firmly
Figure 11.26  The biceps reflex (C5, C6).
on the biceps tendon and hit your finger with the
hammer (Figure 11.26).
• C6–C8 correspond to triceps. Support the person’s
upper arm and let the forearm hang free. Hit the
triceps tendon above the elbow (Figure 11.27).

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 Musculoskeletal assessment Chapter 11

Figure 11.27  The triceps reflex (C6, C7).

Mechanical tension tests

The upper limb tension test (ULTT) is referred to as the
SLR test of the cervical spine. This test mobilises the bra­
chial plexus and particularly biases the median nerve to
determine the degree to which neural tissue is responsible
for producing the patient’s symptoms. Certain movements
of the arm, shoulder, elbow, wrist and hand, and, simi­
B
larly, the neck and the lower limb, can cause neural move­
ment in the cervical spine. These tests are so important
that all physiotherapists should know and use them Figure 11.28  (a) Upper limb tension test (ULTT). (b) ULTT
(Butler 1991). with contralateral right side flexion of the cervical spine.
The physiotherapist depresses the patient’s shoulder,
then adds in 90 degrees abduction, 90 degrees lateral
rotation of the shoulder, elbow extension, forearm supina­
in their spacing are not uncommon and may not be clini­
tion, and wrist and finger extension to the supine patient
cally significant (Maitland 2001).
(Figure 11.28a). Sensitising manoeuvres such as ipsilateral
Soft-tissue changes, including sub-occipital thickening
(same side) or contralateral (opposite side) cervical rota­
and shortening in the extensors and prominence, and
tion and side flexion are added (Figure 11.28b). Symptoms
thickening of the articular pillar of C2–C3 facet joints, are
of pain, paraesthesia and restriction are noted and com­
common in degenerative disorders. Soft-tissue changes
pared with the other side. Common findings will be
around the cervicothoracic junction are also commonly
reduced range or the reproduction of symptoms on the
found and may be referred to as a Dowager’s hump.
affected side.

Palpation
Palpate the soft tissues, noting the positions of vertebrae
and myofascial trigger points (localised irritable spots
within skeletal muscle). These trigger points produce local
pain in a referred pattern and often accompany chronic
musculoskeletal disorders. Palpation of a hypersensitive
nodule of muscle fibres of harder than normal consistency
is the physical finding typically associated with trigger
points (Alvarez and Rockwell 2002).
Observe for local or referred pain, thickening of struc­
tures or stiffness. Remember that anomalies of the bifid
spinous processes of the cervical vertebrae and differences
Bony anomalies
Osteophytes may be palpable at the C2–C3 facet joints in
patients with pre-existing spinal pathology (Maitland
2001). Approximation of the spinous processes of C6–C7
is also a common feature.
Accessory spinal movements
With the patient prone, central pressure on the spinous
processes C2–T6 and unilateral pressures on the articular
pillars C2–T6 is applied by the physiotherapist, noting
levels of stiffness, pain response, muscle spasm and areas
of hypermobility (Figure 11.29).

229
 Tidy’s physiotherapy
A B
Figure 11.29  Accessory movements: (a) central posteroanterior pressure on spinous process; (b) central posteroanterior with
thumbs superimposed; (c) unilateral pressure on the left articular pillar.
CASE STUDY
CERVICAL SPINE
A 50-year-old woman with a 2-year history of central
neck and occasionally bilateral shoulder pain (4 on the
VAS) was referred for physiotherapy. On examination she
had a marked protracted cervical spine (poking chin
posture) which could, however, be corrected by the
patient on demand. Her cervical range of movement was
approximately two-thirds on all movements. Neurological
testing was normal. Palpation revealed stiffness at levels
C5 and C6 to central posteroanterior pressures over the
spinous processes.
The patient was treated with grade III posteroanterior
central pressures (as in Figure 11.29) and was given
postural correction exercises. Priority one cervical neutral
shin slides against a wall. Following three treatment
sessions her pain was reduced to 1 on the VAS and her
range of movement was almost full. She was given deep
flexor exercises on the fourth visit, along with exercises
for normal range of movement. On the fifth visit she was
asymptomatic and was discharged to continue with the
exercises at home.
Both manipulations and mobilisations aim to reduce
pain and increase the joint range of motion for spinal
conditions (Johnson and Rogers 2000; Maitland 2001).
Studies have shown that cervical mobilisation produces a
hypoalgesic (pain-relieving) effect and can decrease visual
Peripheral joint assessments
THE SHOULDER JOINT
Key point
The patient should be suitably undressed to view the
cervical spine, thoracic spine, shoulder girdles, shoulders
and both arms.
230
C
analogue scores (Sterling et al. 2001). The majority of
studies conclude that spinal mobilisations have a positive
short-term effect on pain (Coulter 1996; Bronfort et al.
2001). Koes et al. (1992) observed an improvement in
physical functioning when compared with other
physiotherapy modalities, placebo or GP involvement. It
could be argued that by improving pain in the short term
the patient will return to normal activities more quickly
and thus avoid the potential for deconditioning and
chronicity.
Muscle imbalance procedures were instituted into the
woman’s programme to improve the patient’s postural
awareness, to increase the strength of the deep cervical
flexors and to stretch out the tight sub-occipital
extensors. According to Heimeyer et al. (1990) it is
important for the therapist to differentiate between
people who have protracted chin posture but who can
voluntarily correct it and those who cannot. For the
person in this case study, the posture was correctable, so
the role of the physiotherapist as advisor was paramount.
Repeated sessions of electrotherapy, for example, would
have been inappropriate or would have provided only a
short-term solution to the pain. Treatment should be
geared towards behaviour modifications – the change of
bad postural habits. In this case, the combination of
manipulative therapy, corrective exercises and advice was
employed with success.
Posture
It is important to assess the posture of the cervical and
thoracic spine because a scoliosis, kyphosis or poking
chin posture will affect the mechanics of the shoulder
by altering the plane of the glenohumeral joint. The
spinal and shoulder complex postures should be ob­­
served with the patient in both sitting and standing
positions.

Posterior alignment
The shoulders should ideally be level, but for a right-
handed person the right shoulder is often held lower than
the left and vice versa. Elevation of the shoulder girdle may
be a result of tightness or over-activity in the levator scapu­
lae or the upper fibres of trapezius, and lengthening or
weakness in the lower fibres of trapezius.
Observe the symmetry of the scapulae. They should lie
flat against the thoracic wall and the medial borders
should lie approximately 50–75 mm lateral to the spine.
Winging of the scapulae is observed when the whole
length of the medial border of the scapula is displaced
laterally and posteriorly from the wall of the thorax. This
may result from weakness in the serratus anterior muscle
or a lesion of the long thoracic nerve. Pseudo-winging of
the scapulae occurs when the inferior angle of the scapula
is displaced from the thoracic wall.
Observe the soft-tissue contours of the shoulder for
symmetry, and areas of atrophy and hypertrophy. The
acromion processes should be horizontal to, or slightly
higher than, the point at the root of the scapula. If the
root of the scapula is higher this indicates tightness or
over-activity of the levator scapulae and rhomboid mus­
culature, which causes a downward rotation of the glenoid
fossa. This may be a precursor to impingement syndromes
and rotator cuff pathologies. Moreover, the levator scapu­
lae may cause anterior shear on the cervical spine and give
rise to cervical and scapula pain.
Anterior alignment
Note any irregularities of the clavicle, sternoclavicular and
acromioclavicular joints resulting from previous fractures
or dislocations. Note the soft-tissue contours regarding
symmetry atrophy and hypertrophy, particularly in the
deltoid, upper trapezius and sternocleido-mastoid muscles.
Lateral alignment
Note the relative positions of the humeral head: no more
than one-third of the humeral head should lie anteriorly
to the acromion process. Excessive forward translation
may result from tightness in the pectoral muscles and
elongation of the posterior shoulder capsule. The patient’s
arms should lie comfortably at the side with the thumbs
facing almost forwards. Excessive medial rotation of the
shoulders will result in the thumbs facing inwards towards
the body. Excessive protraction of the shoulders with an
increased thoracic kyphosis and tightness in the pectoral
muscles is a common faulty posture.
Palpation
Palpate the local skin temperature, noting any increase
suggestive of underlying inflammation. Palpate the
acromioclavicular and sternoclavicular joints, observing
for pain or tenderness. Palpate the supraspinatus and
Musculoskeletal assessment Chapter 11
infraspinatus tendons for tenderness associated with ten­
donitis, calcification and strain. Palpate the upper trape­
zius and levator scapulae for tenderness and trigger points.
These hyperirritable areas within the muscle and connec­
tive tissue are thought to be caused by a secondary tissue
response to disc or joint disorders (Hubbard and Berkhoff
1993). They are painful to compression and may cause
referred pain.
Muscle length tests
Levator scapulae
With the patient supine, flex and lateral flex the cervical
spine away to resistance and add ipsilateral rotation
(rotation to the same side as side flexion). Depress the
shoulder girdle and compare range and pain response
on both sides.
Pectoralis minor
With the patient supine, the lateral border of the spine of
the scapula should be within 25 mm of the plinth. If
pectoralis minor is shortened, the lateral border of the
spine of the scapula is more than 25 mm from the plinth
since the shoulder girdle is protracted.
Movements
Clinical note
As the cervical and thoracic spines may refer pain to the
shoulder and scapula areas, full active movements and
accessory movements of these areas should be assessed.
Note any increase or referral of pain around the shoulder
or scapula areas. Over-pressure may be used if the
movements are pain-free. Furthermore, the ULTT may be
performed to rule out referral of pain from neural
structures. Refer to the objective assessment of the
cervical spine for descriptions of these techniques.
Active movements
Full active movements of the shoulder girdle and joint are
performed, noting any restriction, asymmetry and pain
response.
Shoulder girdle movements
Assess shoulder girdle elevation, depression, protraction
and retraction, observing for pain asymmetry and crepitus.
Shoulder joint flexion
Observe flexion through to elevation and return of move­
ment, assessing the scapulohumeral rhythm. Normal
should be in the ratio of 2 : 1 (humerus : scapula). Reversed
scapulohumeral rhythm occurs in conditions causing
231
 Tidy’s physiotherapy
Figure 11.30  Reversed scapulohumeral rhythm of the right
shoulder.
restriction of the glenohumeral joint, such as adhesive
capsulitis (‘frozen shoulder’).
Shoulder joint abduction
Observe abduction through to elevation and return (Figure
11.30), again noting the scapulohumeral rhythm.
Key point
A painful arc of movement is observed in patients
suffering from impingement syndromes, whereby the
superior aspects of the rotator cuff, biceps tendon and
bursae are impinged by repetitive overarm activities. Pain
is experienced between 90 and 130 degrees of
abduction.
Impingement may be caused by loss of scapular stabil­
ity. Faulty patterns of scapula motion include early rota­
tion and elevation of the scapula (reversed scapulohumeral
rhythm). This may implicate weakness in the stabilisers
(e.g. lower fibres of trapezius, rhomboids and serratus
anterior) or shortness and over-activity in the upper trape­
zius and levator scapulae.
Impingement may also be caused by weakness or inhibi­
tion of the rotator cuff muscles that produces a superior
translation of the humeral head (i.e. subscapularis, teres
minor and lower infraspinatus). There may also be late
timing of lateral rotation during abduction which may
cause impingement.
232
Tightness of pectoralis minor can cause increased pro­
traction of the scapula which decreases the subacromial
space.
Repetition of the movement may induce an element of
fatigue and abnormal movements may derive from that.
A juddering movement of the scapula on return from
elevation implicates poor eccentric control.
Differentiation. If abduction reproduces the person’s
pain, then differentiation between the glenohumeral and
subacromial structures may be required.
1. If the movement is repeated and compression applied
to the glenohumeral joint causes an increase in
symptoms, then the glenohumeral joint is implicated.
2. If the movement is repeated and a longitudinal force
in a cephalad direction is applied (increasing
compression on the subacromial structures), with an
increase in pain, the subacromial structures are
implicated.
Failure to initiate or maintain abduction when placed
passively into abduction is a sign of rotator cuff rupture
and the patient should be referred to a consultant for a
repair/further investigations.
Shoulder joint rotation
Test medial and lateral rotations, both beside the trunk
and at 90 degrees of abduction. Note the pain response
and limitation of movement.
Shoulder joint horizontal flexion and
extension (scarf-test)
Pain on these movements implicates the acromioclavicu­
lar joints as the source of pain or restriction.
Clinical note (Figure 11.31)
The medial kinetic rotation test assesses movement
dysfunction and impingement and instability risk at the
shoulder.
The patient is supine with the arm at 90 degrees of
abduction and off the plinth. The therapist stands above
the patient’s right shoulder facing his/her feet and places
his/her left index finger on the patient’s humeral head
and the left middle finger on the coracoid process. She/
he passively medially rotates the patient’s shoulder using
the forearm to 70 degrees.
In an ideal situation, or negative test, the therapist’s
fingers on the left hand should not move while rotating
the shoulder joint medially to 70 degrees.
Early movement of the humeral head (index finger)
suggests an anterior instability of the glenohumeral joint.
Early movement of the coracoid (middle finger)
suggests scapula instability and a potential impingement
risk at the glenohumeral joint.

Shoulder joint extension
Compare both sides for range and pain response.
Shoulder functional movements
Functional movements, such as the hand behind the back
(HBB), and the hand behind the neck (HBN), should also
be assessed. These movements are grossly restricted in
patients with adhesive capsulitis.
Other shoulder joint abnormalities
Sporting activities that give rise to symptoms, such as the
late cocking stage of throwing a ball overhead, should also
be assessed to determine faulty mechanics.
Passive movements
All movements performed actively can be repeated
passively, noting the differences in range. Observe the
differences in end-feel and compare these with the unaf­
fected side.
Figure 11.31  Medial kinetic rotation test.
A B
Figure 11.32  (a) Lateral glide of the glenohumeral joint. (b) Caudal glide of the shoulder in elevation.
Musculoskeletal assessment Chapter 11
Key point
Note that the capsular pattern for the glenohumeral joint
is limitation of lateral rotation, abduction and medial
rotation (Cyriax 1982).
Accessory movements
Acromioclavicular and sternoclavicular joints
Test anteroposterior (AP) and posteroanterior (PA) draw,
and caudal glide.
Glenohumeral joint
Test anteroposterior (AP) and posteroanterior (PA)
draw, caudal and cephalad glide, and lateral distraction
(Figure 11.32).
Further tests (Maitland 2001)
The following tests should be performed only in shoulders
of low irritability and when no comparable sign has been
found. They stress a number of different structures around
the shoulder and are therefore not diagnostic:
• locking test of the shoulder;
• quadrant test of the shoulder (Figure 11.33).
Resisted muscle testing
This provides a guide of strength ratios and pain response.
Test: abduction and flexion at around 30–60 degrees;
internal and external rotation beside the trunk (Figure
11.34) and at 90 degrees of elevation in the plane of the
scapula; and resisted muscle testing in positions of func­
tion and/or pain.
Muscle length tests
It may be useful to test the length of muscles that are prone
to shortness – latissimus dorsi, pectoralis major and
minor, upper fibres of trapezius, levator scapulae and
sternocleido-mastoid.
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 Tidy’s physiotherapy
Figure 11.33  Quadrant test of the shoulder.
A around 30 degrees of abduction, 45 degrees of lateral rota­
B is applied on the anterior aspect of the humeral head.
Figure 11.34  (a) Resisted lateral rotation at the shoulder.
(b) Resisted medial rotation at the shoulder.
Acromioclavicular joint compression
and distraction
End-of-range overpressure into horizontal flexion com­
presses the acromioclavicular joint and may give rise to
pain arising from this joint. Acromioclavicular distraction
tests the instability of the acromioclavicular joint by
234
Figure 11.35  Anterior draw of the glenohumeral joint in
abduction with stabilisation of the shoulder girdle.
applying a downward traction on the arm while palpating
the joint line. Reproduction of pain or palpable separation
of the joint line is a positive test.
Tests for shoulder instability
Anterior draw/translation
(Lachmann’s of the shoulder)
This is performed in supine with the patient’s arm at
tion and slight flexion. The physiotherapist grasps the
humeral head with one hand and the medial hand is
used to stabilise the shoulder girdle. The lateral hand
applies the anterior translation force in the same way
as the anterior draw test of the knee. Laxity of the
joint (excessive anterior translation) is a positive sign
(Figure 11.35).
Posterior draw test
This is performed in supine with the patient’s gleno­
humeral joint at the edge of the examination couch in
abduction not exceeding 90 degrees. Posterior pressure
Excessive movement compared with the other side is a
positive sign.
Inferior draw (sulcus) test (Figure 11.36)
This is performed in sitting or supine, arms by the sides.
The physiotherapist exerts a strong downward traction
force on the arm, grasping the head of the humerus with
both hands, to the limit of movement, pain or apprehen­
sion while monitoring the superior contour of the shoul­
der joint. Excessive inferior glide or a significant depression
or sulcus distal to the acromion is a positive sign.

Figure 11.36  Inferior draw (sulcus) test. Courtesy of Nina Dean
and Gemma Dickinson.
Figure 11.37  The empty-can test position. Resistance to
abduction is applied by the therapist.
Medial kinetic rotation test
The shoulder is positioned and supported in 90 degrees
abduction and passively medially rotated to 70 degrees.
The therapists index and middle fingers are placed on the
corocoid process and anterior humeral head. Anterior
translation of the corocoid before 70 degrees rotation may
suggest scapula instability whilst anterior translation of
the humeral head before 70 degrees rotation may indicate
glenohumeral instability.
Impingement test
Supraspinatus (empty-can test)
This is performed in sitting or standing with 90 degrees of
abduction bilaterally, full available medial rotation and 30
degrees of horizontal flexion (Figure 11.37). Supraspinatus
is the main support for the suspended arm in this
Musculoskeletal assessment Chapter 11
Figure 11.38  Palpation of the supraspinatus tendon.
The patient’s hand is behind the back.
position. The physiotherapist resists abduction of the
shoulder. Pain on resistance is a positive test for a lesion
of the supraspinatus muscle or tendon. Following the
objective assessment, record your findings clearly and
asterisk objective findings.
Test yourself
Match these five scenarios to the likely pathology.
1. Reduced range of movement particularly on active
and passive rotations and abduction.
2. Painful arc of movement between 90 and 120
degrees.
3. Inability to actively abduct the arm away from the
body and maintain the position when the arm is
placed there passively.
4. Pain and weakness on resisted elbow and shoulder
flexion.
5. Excessive movement on passive anterior, posterior and
sulcus draw tests of the shoulder.
Answers
(1) Frozen shoulder (adhesive capsulitis). (2) Impingement
of supraspinatus under the acromion. (3) Rupture of the
rotator cuff musculature. (4) Ruptured biceps brachii muscle.
(5) Global instability.
THE HIP JOINT
Gait
Observe the person’s gait from the front, back and side.
Assess the patient with and without a walking aid, as
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 Tidy’s physiotherapy
Key point
The patient should be suitably undressed to view the hip,
pelvis and spine. Note that the hip joint is too deep to
observe an effusion or palpate the joint line.
deemed appropriate. Ask the patient to walk forwards and
backwards, while observing:
• stride length symmetry;
• the time spent on the single leg support phase on
each leg;
• corresponding factors of pain, stiffness and/or
weakness during the cycle.
Posture
Standing
With the patient standing, view from the front, rear and
sides. Note:
1. Pelvic tilting: a line joining the two anterior
sacroiliac joints should be horizontal (the same
applies posteriorly).
2. The relative levels of the posterior superior iliac
spine to the ipsilateral anterior superior iliac spine
viewed from the side: differences may be suggestive
of sacroiliac rotatory asymmetry.
3. Rotational deformity of the hips: this may be
observed as in-toeing or out-toeing.
4. Leg length discrepancy: this may be observed by the
differences in the horizontal levels of the gluteal and
knee creases.
5. Scoliosis of the lumbar spine: this may be structural
or a compensation for a leg length discrepancy.
6. Inequality of weight distribution: the patient may
reduce the amount of weight borne on the painful
side.
7. Increased lumbar lordosis: this may suggest a fixed
flexion deformity of the hip(s).
8. Bruising in the abdominal or groin area: this is
suggestive of a sportsman’s hernia.
9. Muscle wasting: wasting, particularly of the quadriceps
and gluteal muscles, is common and may appear as
hollowing posteriorly or laterally at the buttocks.
Supine
With the patient supine, note the following.
1. Leg rotation, through observing the relative positions
of the patella and/or the feet.
2. Pelvic rotation.
3. Leg length discrepancy, through observing the
relative position of the medial malleoli or heels.
236
Leg length discrepancy
Apparent leg length discrepancy is measured from the xiphoid
of the sternum to the tip of the medial malleolus using a
tape measure (compare with the other leg). True leg length
discrepancy is measured – using a tape measure – from the
anterior superior iliac spine to the tip of the medial malle­
olus. A difference in leg length of up to 1–2 cm is consid­
ered normal by some clinicians. If there is a leg length
difference, determine if it is the length of the thigh (hip
to knee) or leg (knee to ankle).
Key point
From the movement of supine to sitting, one leg may
appear to be longer in supine and shorter in sitting. This
is caused by anterior rotation of the innominate bone on
the affected side and is a sacroiliac joint dysfunction.
Muscle length assessments
The Thomas test
This test determines the presence of a fixed flexion deform­
ity at the hip. With the patient supine, the hip is fully
passively flexed, and the lumbar lordosis is obliterated. If
the contralateral (opposite) hip rises off the bed, this indi­
cates a fixed flexion deformity of that hip. This may be
owing to tightness or restriction in the capsule, iliopsoas
or rectus femoris.
To differentiate between the iliopsoas and rectus femoris
as the source of restriction, the patient’s knee is passively
extended (Figure 11.39). If this results in the patient’s hip
dropping down into less flexion, then the restriction is in
the rectus femoris muscle because by extending the knee
an element of stretch has been removed. If the hip is unaf­
fected and remains, in the same degree of flexion, inde­
pendently of the knee extension, then the restriction is in
the iliopsoas muscle. This is measured and recorded.
The length of the following muscles may be tested as
they are prone to shortening: quadratus lumborum, tensor
fascia lata and the hamstrings.
Modified Ober’s test (iliotibial band)
With the patient in side-lying and the uppermost hip fully
laterally rotated and the knee joint in unlocked extension,
the uppermost leg should drop (adduct) to the plinth
(Figure 11.40). A tight iliotibial band would result in the
leg not being able to adduct to the plinth.
Piriformis test
With the patient supine, or side-lying, with hip at 90
degrees flexion, adduct maximally to resistance and exter­
nally rotate. (Note piriformis is a medial rotator in flexion.)
Pain in the buttock or in the distribution of the sciatic

Figure 11.39  The Thomas test: (a) normal; (b) abnormal.
Figure 11.40  Modified Ober’s test.
nerve may signify compression of the sciatic nerve by the
piriformis muscle (Figure 11.41).
Hamstrings
With the patient sitting with spine in neutral and the hip
at 90 degrees, the person should be able to extend the knee
to within 10 degrees of full extension (Figure 11.42).
Quadratus lumborum
Test side flexion against a wall without associated flexion
or rotations. Compare the two sides. A shortened
Musculoskeletal assessment Chapter 11
Figure 11.41  Piriformis stretch. Note that, in the flexed
position, piriformis becomes a hip medial rotator.
Figure 11.42  Assessment of hamstring length. Note that the
lumbar spine remains in neutral. This picture shows normal
hamstring length.
quadratus lumborum will result in limitation of contral­
ateral side flexion.
Movements
Allow the patient to functionally demonstrate his or her
aggravating movement in order to determine the likely
structures implicated in producing the symptoms.
Lumbar spine differentiation
The lumbar spine may give rise to referred pain in the
region of the hip or groin so it is important to exclude the
lumbar spine as a possible cause of symptoms arising at
the hip joint. Flexion, extension and bilateral side flexion
should be observed actively in standing. Loss of range of
motion and pain response should be noted, particularly if
these movements reproduce the patient’s hip pain or the
patient’s comparable sign. If the movements are pain-free
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 Tidy’s physiotherapy
and full range, then overpressure may be applied to
observe whether this reproduces the patient’s symptoms.
Accessory movements of the lumbar spine, femoral nerve
stretch and SLR should also be screened.
Trendelenberg test
A positive Trendelenburg test demonstrates that the hip
abductors are not functioning owing to weakness or pain
inhibition, and are unable to perform their role of stabilis­
ing the pelvis on the weight-bearing leg. To perform the
test the patient stands on the unaffected leg and flexes the
other knee to a right-angle. The pelvis should remain level
or tilt up slightly on the non-weight-bearing side. The
patient then stands on the affected leg and flexes the knee
of the other leg. If the pelvis drops on the non-weight-
bearing side this signifies a positive Trendelenberg test
(Figures 11.43 and 11.44).
A B
Figure 11.43  Trendelenburg test of right hip abductors: (a) normal; (b) abnormal or positive sign.
238
Palpation
• Palpate the head of the femur lateral to the femoral
artery.
• Rotate the hip passively to elicit crepitus or
tenderness at the joint.
• Palpate the psoas major and adductor longus
tendons to localise strains and contractures of these
structures.
• Palpate the greater trochanter of the femur for
tenderness associated with bursitis. Palpate the
ischial tuberosity for suspected hamstring strains.
• Tenderness located over the anterior superior iliac
spine may indicate a strain of the sartorius muscle or
contusion of the spine following contact sports. This
is referred to as a ‘hip-pointer’.
• Palpate the lower abdominal musculature for
suspected inguinal or sports hernias.

Active movements
Key point
Note pain, crepitus and/or limitation of movement. Apply
overpressure to the movement if it is pain-free to see
whether this reproduces the symptoms not elicited on
other movements. Measure both the normal and
affected hip for comparison.
Hip flexion/extension
The patient is supine or side lying. The axis of the goni­
ometer is placed directly over the greater trochanter of the
femur. The static arm should be parallel to the patient’s
trunk. The dynamic arm should be placed parallel to the
femur. Note loss of range or pain response.
Hip abduction/adduction
The patient is supine. The axis of the goniometer is
placed over the anterior superior iliac spine. The static
arm should be in line between the left and right anterior
superior iliac spine. The dynamic arm should be parallel
to the long axis of the femur. Note loss of range or pain
response.
Hip rotation
Hip rotation can be easily measured with the patient
sitting. Note that the hip joints are approximately
Normal hip Weak hip
abductors abductors
Negative Positive
Figure 11.44  Schematic of Trendelburg’s sign.
Musculoskeletal assessment Chapter 11
90 degrees flexed (Figure 11.3). The axis of the goniometer
is placed at the mid-point of the patella. The static arm
is perpendicular to the floor. The dynamic arm should
be parallel to the anterior midline of patella. If active
movements are full range and pain free then gentle over­
pressure can be applied noting any reproduction of
symptoms.
The normal ranges of movement at the hip joint should
be approximately:
• 0–120 degrees for unilateral flexion, 0–150 for
bilateral flexion;
• 10–15 degrees for extension;
• 0–40 degrees for abduction;
• 0–25 degrees for adduction;
• 0–35 degrees for medial rotation;
• 0–45 degrees for lateral rotation (Figure 11.45).
Passive movements
Flexion, extension, abduction, adduction, internal and
external rotation should be performed passively by the
therapist (Figure 11.46). Note any differences between
active and passive ranges and identify reasons for this.
Muscle strength testing
Test the muscles both isometrically and isotonically
through range to detect weakness at any particular point
in the range. Compare with the opposite side. Pain inhib­
its muscle contraction and it is therefore important to
differentiate between true weakness and pain-induced
inhibition.
With the patient side-lying, test the strength of the hip
abductors and adductors (weakness of adductors is a
common finding in recurrent groin strains). With the
patient supine, test the strength of the hip adductors,
flexors and medial/lateral rotators (Figure 11.45).
Figure 11.45  Resisted lateral rotation of the hip in flexion.
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 Tidy’s physiotherapy
Figure 11.46  Passive hip and knee flexion.
Figure 11.47  Compression applied through the hip joint.
Accessory movements
Test:
• cephalad longitudinal accessory movement
(Figure 11.47);
• caudad longitudinal accessory movement;
• lateral transverse (joint distraction).
Flexion/adduction combination and the hip quadrant
test may be performed on non-irritable hips when all
plane movements are clear with overpressure (Figure
11.48; Maitland 2001).
Neural tests
Neural tests may be performed if the symptoms produced
at the hip appear to be originating from neural or spinal
structures:
• femoral nerve stretch test (prone knee bend);
• sciatic nerve stretch test (straight leg raise);
• slump test.
For descriptions of these tests refer to the objective
assessment of the lumbar spine.
240
Figure 11.48  Quadrant test of the hip (flexion and
adduction).
Functional tests
Observe the patient performing activities that reproduce
their pain. If appropriate, assess activities such as hop,
squats, walking forwards, backwards, sideways, etc.
Key point
On completion of the assessment, specific objective signs
that reproduce the patient’s symptoms should be marked
with an asterisk (*) or highlighted. This is commonly
referred to as a ‘comparable sign’ and needs to be
reassessed at each treatment to determine the
effectiveness of the physiotherapy intervention. Record
your findings clearly.
Test yourself
Match these five scenarios to the likely pathology.
1. Local tenderness at the ischial tuberosity and pain on
resisted knee flexion.
2. Pain in the groin on coughing, resisted adduction
sit-ups and weight-bearing.
3. A three-year history of pain and stiffness particularly
on medial rotation.
4. Local tenderness and heat palpated in the area of the
greater trochanter having an insidious onset.
5. Increased or exaggerated lumbar lordosis and a
positive Thomas test.
Answers
(1) Hamstring strain. (2) Sportsman’s hernia.
(3) Osteoarthritic (OA) hip. (4) Trochanteric bursitis.
(5) Tightness in the hip flexors (iliopsoas.)
 Musculoskeletal assessment Chapter 11

THE KNEE JOINT

Key point

The patient should be suitably undressed to view the hip,

knee and ankle joints.

Gait
Observe the person’s gait as they walk forwards and back­ A B C
wards. Make particular note of the equality of stride
length, dwell time on each leg, reluctance to bear weight Figure 11.49  Leg posture deformities: genu varum (bow
legs); (b) genu valgus (knock-knees); (c) genu recurvatum
and any pain responses.
(hyperextending knees).

Clinical note

The hip joint may refer pain to the knee. To differentiate

between the hip and knee joints as a source of ASIS
symptoms, the hip joint is tested by observing full flexion
of the hip joint and then medial and lateral rotation in
90-degree flexion passively. Observe for any pain
response or limitation of movement compared with the Q
other side. If the movements are full range and pain-free,
it is unlikely that the hip joint is the source of pain
(Figure 11.45).

Knee examination
Posture with patient standing
Observe any deformities such as genu varum, genu valgus
or genu recurvatum (Figure 11.49). Note any evidence of
muscle atrophy, particularly evident in the vastus medialis
muscle. Observe the relative positions and size of the Figure 11.50  Measuring the Q angle.
patellae. ‘Patella alta’ is the term used to describe a small
high riding patella.
Note any foot, ankle or subtalar deformity, such as foot
pronation, which will cause medial rotation of the tibia
and, hence, affect the mechanics of the knee joint. Clinical note

Swelling and discoloration
Swelling that extends beyond the joint capsule may suggest
an infection or a major ligamentous injury, and the supra­
patellar pouch will appear distended.
Bruising may suggest trauma to superficial tissues or
ligaments. Redness of the skin suggests an underlying
inflammation. Palpate the temperature around the knee
joint with the back of the hand: heat is indicative of an
underlying inflammatory disorder.
On your patient, draw a straight line across the middle
of the patella. From the centre of this, draw a straight
line going downwards through the centre of the tibial
tuberosity and another going upwards towards the
anterior superior iliac spine (Figure 11.50). Normal values
are approximately 12 degrees for males and 15 degrees
for females. An increase in the Q angle is a predisposing
factor in anterior knee pain and lateral dislocation of the
patella.

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 Tidy’s physiotherapy
Clinical note
An effusion (swelling confined within the joint capsule)
will appear to obliterate the natural hollows at the sides
of the patella. The synovial membrane of the knee is
expansive and extends the width of 3–4 fingers above
the superior aspect of the patella.
Observe scar tissue that may be indicative of previous
surgery or trauma.
Loss of muscle bulk
Observe loss of bulk in the quadriceps muscles, particu­
larly in the vastus medialis which atrophies earlier than
vastus lateralis following trauma, degenerative diseases
and pain episodes. Measure the circumference of both
thighs at 5, 8, 15 and 23 cm above the upper pole of the
patella with a tape measure to obtain an objective marker
(Magee 1992).
Ask the patient to perform a static quadriceps contrac­
tion. Palpate the tone, compare left with right sides of the
musculature. Inability to actively extend the knee may
result from rupture of the quadriceps tendon or quadri­
ceps weakness, patella fractures, rupture of the patellar
ligament, or avulsion of the tibial tubercle. Note any loss
of tone in the anterior and posterior tibial muscles and,
again, measure, if appropriate, at specific recorded dis­
tances below the patella.
Patellar tap
Patellar tap is a simple test to determine the presence of
an effusion at the knee joint. It is performed with the
patient supine. Any excess fluid is squeezed out of the
suprapatellar pouch by sliding the index finger and thumb
from 15 cm above the knee to the level of the upper
border of the patella (Figure 11.51). Then, place the tips
of the thumb and three fingers of the free hand squarely
Figure 11.51  Patellar tap test.
242
on the patella and jerk it quickly downwards. A ‘click’
sound indicates the presence of effusion. The test will,
however, be negative if the effusion is gross and tense, such
as with a haemarthrosis of the knee (blood within the
joint) following an anterior cruciate rupture.
Fluid displacement test
This is performed as above, by squeezing excess fluid out
of the suprapatellar pouch and then stroking the medial
side of the knee joint to displace any excess fluid in the
main joint cavity to the lateral side of the joint. Repeat this
procedure by stroking the lateral side of the joint. Any
excess fluid will be seen to move across the joint and
distend the medial side of the knee.
Tenderness at the knee (tibiofemoral joint)
Identify the joint line clearly by flexing the knee and
observing for hollows at the sides of the patella ligament
– these lie over the joint line.
1. Tenderness at the joint line is common in meniscal
and fat pad injuries.
2. Tenderness along the line of the collateral ligaments
of the knee joint is common at the site of a lesion
following a tear, particularly at the upper and lower
attachments, and at the ligament’s midpoint.
Associated bruising and oedema may also be a
feature of acute injuries.
3. Tenderness at the tibial tubercle – in children
and adolescents, tenderness and hypertrophy
of the tibial tubercle prominence – is associated
with Osgood Schlatter’s disease. Tenderness
is also found following acute avulsion
injuries of the patella ligament and its tibial
attachment.
4. Tenderness and swelling in the popliteal fossa may
indicate the presence of a Baker’s cyst. This condition
is associated with degenerative changes or
rheumatoid arthritis involving the knee joint.
5. Tenderness at the adductor tubercle may indicate
strain in the adductor magnus muscle.
6. Femoral condyle tenderness may indicate the
presence of osteochondritis dessicans.
Patellofemoral joint assessment
A knee assessment should include assessment of both the
tibiofemoral and patellofemoral joint. Observe the posi­
tion of the patella and compare both sides.
• Determination of a high or small patella
(patella alta) is made by calculating the ratio
of the length of the patellar tendon to the
longest diagonal length of the patella. The normal
value for this ratio is 1.02 ± 20% (Simmons and

Cameron 1992). Patella alta is a predisposing factor
in anterior knee pain and recurrent dislocation of
the patella.
• Observe any tilting, lateral glide and rotation of the
patella during a quadriceps contraction. Compare
this with the other side.
• McConnell (1996) described a ‘critical test’ for the
patellofemoral joint. Resisted inner-range quadriceps
contraction is performed with the patient sitting at
various degrees of knee flexion to determine whether
this reproduces the patient’s symptoms. Compare
both sides (Figure 11.52).
• The McConnell critical test may be repeated with the
patella taped in the corrected position. This will
determine whether the taping is effective and should
be incorporated into the treatment programme.
Taping is believed to enhance activation and earlier
timing of vastus medialis in quadriceps contractions
and thus restore patellar tracking to normal.
• Observe any excessive pronation of the feet which
may increase the Q angle (Figure 11.50).
• Test for tightness in the following structures: lateral
retinaculum, iliotibial band, hamstrings and calves.
Tightness of the above structures will increase
dorsiflexion and therefore pronation of the foot and
ankle during the gait cycle. All of this will increase
the Q angle (Olerud and Berg 1984).
• Perform passive accessory movements to test the
mobility and pain response of the patella in all
directions. Observe pain, laxity or muscle spasm.
• Perform Clarke’s test. The patient is asked to contract
the quadriceps while the patella is pressed firmly
down against the femur. Pain is produced in
conditions such as chondromalacia or osteoarthritis
affecting the patellofemoral joint.
Figure 11.52  Critical test for patellofemoral pain. The test
works because of the different contact areas of the patella
against the femoral condyles in varying degrees of knee
flexion.
Musculoskeletal assessment Chapter 11
Movements
Active movements
The patient is in half lying. Measure the active range of
flexion and extension on each leg. The normal range of
movement at the knee joint is approximately minus 5
degrees to 135 degrees of flexion. Note limitations of pain,
stiffness or spasm. Overpressure the movement if full
active movement is pain-free.
The axis of the goniometer should be positioned over
the lateral femoral condyle. The static arm should be paral­
lel with the long axis of the femur towards the greater
trochanter. The dynamic arm should be positioned paral­
lel to the long axis of the fibula and lateral malleolus
(Figure 11.53). Hyperextension is present if the knee
extends beyond 0 degrees (i.e. when the tibia and femur
are in line).
Failure to hyperextend or lock out the knee fully may
be a sign of a meniscal tear that is blocking the movement
of the joint. Moreover, a springy end-feel may be indicative
of a bucket-handle tear of the meniscus. A rigid block
to extension is common in arthritic conditions affecting
the knee.
Passive movements
Check the range of extension and flexion passively. If there
is a difference in active and passive range determine
reasons for this.
Valgus stress test (medial collateral ligament
of the knee)
With the patient supine, the physiotherapist applies a
valgus force to the knee joint (i.e. the femur is pushed
medially, and the leg pulled laterally) while the joint is
held in extension (Figure 11.54a). A positive sign is
Figure 11.53  Measuring knee flexion using a 360-degree
goniometer.
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 Tidy’s physiotherapy
A A
B B
Figure 11.54  Stress tests: (a) valgus; (b) varus.
observed as excessive opening up on the medial side of
the joint. With the knee held in extension, a positive sign
suggests major ligamentous injury involving the medial
collateral, posterior cruciate and potentially the anterior
cruciate. The test is performed again with the knee in
20–30 degrees of flexion.
Varus stress test (lateral collateral ligament
of the knee)
With the patient supine, the physiotherapist applies a
varus force to the knee joint (i.e. the femur is pushed later­
ally, and the leg pulled medially) while the joint is held
in extension (Figure 11.54b). A positive sign is observed
as excessive opening up on the lateral side of the joint. As
with the valgus stress test, with the knee held in extension
a positive sign suggests major ligamentous injury involv­
ing the lateral collateral, posterior cruciate and, poten­
tially, the anterior cruciate. The test is performed again
with the knee in 20–30 degrees of flexion.
Anterior draw test (anterior cruciate ligament)
With the patient crook lying, the physiotherapist sits on
the patient’s foot to stabilise the leg and grasps around the
244
Figure 11.55  Draw tests: (a) anterior; (b) posterior.
proximal tibia and tibial tuberosity and pulls the tibia
forwards (Figure 11.55a). A positive sign is elicited by
excessive translation of the tibia anteriorly (the normal
translation is approximately 6 mm). Translation of 15 mm
confirms rupture. Compare this with the other side. This
test also stresses the posterior joint capsule, the medial
collateral ligament and the iliotibial band (Magee 1992).
Clinical note
Figure 11.56 illustrates the positive posteroanterior draw
following rupture of the anterior cruciate ligament.
Posterior draw test (posterior cruciate ligament)
With the patient crook lying, the physiotherapist sits on
the patient’s foot to stabilise the leg and grasps around the
anterior aspect of the proximal tibia and pushes the tibia
backwards (Figure 11.55b). A positive sign is elicited by
excessive translation of the tibia posteriorly. Compare this
with the other side. This test also stresses the arcuate-
popliteus complex, posterior oblique ligament and ante­
rior cruciate ligament (Magee 1992).

Figure 11.56  Schematic of positive posteroanterior draw
following rupture of the anterior cruciate ligament.
Figure 11.57  Lachman’s test.
Clinical note
A ‘sag sign’ is observed with the patient in crook lying,
whereby the tibia is posteriorly displaced in relation to
the femur. Posterior displacement may give the false
impression that the patient has a rupture of the anterior
cruciate ligament, as when an anterior draw test is
performed a considerable amount of movement is noted.
This is a result of the tibia returning to its normal
position, however.
Lachman’s test (modified anterior draw test)
The patient is supine with the knee resting over the physi­
otherapist’s thigh at around 20–30 degrees of flexion
(Figure 11.57). The physiotherapist grasps around the
medial proximal aspect of the tibia with the right hand.
The lateral aspect of the patient’s femur is stabilised by the
therapist’s left hand. Anterior and posterior translation of
the tibia is produced by the physiotherapist’s right hand.
This tests the anterior cruciate, the posterior oblique liga­
ment and the arcuate-popliteus complex (Magee 1992).
The Lachman test has been shown to be sensitive for the
diagnosis of anterior cruciate injury (Kim and Kim 1995).
Musculoskeletal assessment Chapter 11
The pivot shift test
This is a test for anterolateral instability of the knee joint.
With the foot in medial rotation and the knee in 30
degrees of flexion, a valgus stress is applied to the knee
while simultaneously extending it. A ‘clunk’ indicates a
positive test and suggests anterior cruciate ligament
pathology (McRae 1999).
Key point
Peripheral tears of the menisci can now be sutured
arthroscopically. Many authorities believe that McMurray’s
tests described below may be of limited value (Evans
et al. 1993).
McMurray’s medial and lateral meniscus tests
The physiotherapist palpates the medial aspect of the joint
line, and passively flexes and then laterally rotates the
tibia, so that the posterior part of the medial meniscus is
rotated with the tibia. The joint is then moved back from
a fully flexed position to 90 degrees of flexion to test for
the posterior part of the meniscus. A positive test occurs if
pain is elicited, or a snap or click of the joint will occur if
the meniscus is torn. The test is then repeated for the
lateral meniscus by medially rotating the tibia.
Note that the examiner may be able to detect clicking
or snapping sounds when performing this test, as there are
various structures in the knee joint that can produce these
signs. It is thus easy for this test to produce a false-positive
result (Palmer and Epler 1998).
Apley’s compression/distraction test (for
differentiation between meniscus and ligament)
The patient is prone with the knee flexed at right-angles.
The physiotherapist medially and laterally rotates the tibia
while applying a distraction force through the knee joint.
The test is repeated by applying a compressive force
through the knee joint. If the patient’s symptoms are worse
on compression then the symptoms are likely to be arising
from a meniscal injury. Conversely, if they are worse on
distraction then they are likely to be arising from a liga­
mentous injury.
Proprioception
Proprioception is tested with the patient standing on the
unaffected leg and then on the affected leg while main­
taining balance. Progressive adaptations may include
standing on one leg with the eyes closed, standing on a
wobble board, catching and throwing a ball, etc.
Accessory movements
Patellofemoral joint
• Medial, lateral, cephalad and caudad glides.
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 Tidy’s physiotherapy
• Medial and lateral rotation.
• Compression and distraction.
Superior tibiofibular joint
• Anteroposterior and posteroanterior glides.
• Compression.
Tibiofemoral joint
• Anteroposterior and posteroanterior glides.
• Medial and transverse glides.
Quadrant tests
These are performed on non-irritable knees when plane
movements are pain-free.
• Flexion/adduction quadrant.
• Flexion/abduction quadrant.
• Extension/adduction quadrant.
• Extension/abduction quadrant.
Following the objective assessment record your findings
clearly and asterisk objective markers.
Test yourself
Match these five scenarios to the likely pathology.
1. The knee is stiff and painful for about half an hour in
the morning, aches at the end of the day and has
been like that for a long time.
2. The knee locks and has to be jiggled around to
unlock it.
3. Since a tackle last week, the knee keeps giving way
and becomes very swollen.
4. The knee is very red and swollen. The person also
feels feverish and generally unwell.
5. When the person walks downstairs he feels pain
behind his kneecap.
6. There is pain on the inside of the knee and it hurts
doing sideways movements.
Answers
(1) Osteoarthritis. (2) Torn meniscus. (3) Ruptured anterior
cruciate. (4) Infective arthritis. (5) Chondromalacia patella.
(6) Torn medial collateral ligament.
THE ANKLE AND FOOT
Gait
Observe the patient’s gait, both barefoot and with shoes.
Ask the patient to walk backwards and forwards. Assess the
246
Key point
The patient should be suitably undressed to view the
legs, ankles and feet.
normal heel-to-toe pattern and stride length, rhythm, the
posture of the longitudinal arch and weight-bearing on
both feet. Note any pain, stiffness and weakness. Inspect
the patient’s footwear for areas of uneven or greatest wear.
Foot and ankle examination
Pulses (leg circulation)
Palpate the posterior tibial and dorsalis pedis pulses to
establish the state of the distal circulation. Circulation is
often poor in patients suffering from peripheral vascular
disease or diabetes. Compare both sides.
Oedema
Note any oedema, suggesting a systemic rather than a local
cause for the patient’s symptoms. This may indicate heart
failure or excessive water retention. Bruising is suggestive
of muscle or ligament injury. This is commonly situated
on the lateral aspect of the foot beneath the lateral malleo­
lus, following lateral ligament tears.
General condition
Note the skin texture, colour and nail condition, which
identifies the state of the peripheral circulation.
Temperature
Feel for any increase in temperature around the joint and
compare with the opposite foot. A foot with impaired
arterial circulation is colder than normal and may appear
cyanosed (blue); conversely a warm foot may be indicative
of an inflammatory response, for example following an
injury or associated with conditions such as rheumatoid
arthritis.
Tenderness
• Tenderness localised over and just proximal to the
malleoli often occurs following a fracture.
• Tenderness and pain in the area distal and inferior
to the lateral ligaments is common following
inversion sprains. The anterior talofibular
ligament is the most commonly injured as the
ligament is most often torn in the combined
position of inversion and plantar flexion.
This is the loose packed position and one
in which the anterior band of the lateral
ligament is particularly placed on stretch.
 Musculoskeletal assessment Chapter 11

The leg and hindfoot

Clinical note
With the patient prone, the physiotherapist bisects the
calcaneus by drawing a vertical line through the posterior
A pronated foot has the appearance of rolling in on the
aspect of the calcaneus, then bisects the lower leg by
medial side with bulging of the navicular bone medially.
Additionally, the longitudinal arch appears flattened. A
drawing a vertical line on the posterior aspect of the lower
supinated foot has the appearance of rolling outwards third, and places the subtalar joint in a neutral position.
with the inner border raised. If the lines are parallel there is correct alignment of the leg
and hindfoot (Figure 11.58b). Rear foot varus is observed
as the calcaneus appearing to invert relative to the leg
(Figure 11.58a); rear foot valgus is observed as the calcaneus
• Tenderness along the line of the long flexor tendons appearing to evert relative to the leg.
and/or the peroneal tendons may indicate the
presence of tenosynovitis. This may be accompanied
by local thickening.
Key point
• Tenderness at the articular surface of the talus is
common in osteoarthritic conditions.
Complex foot misalignments may require referral to a
• Tenderness at the heel is found in conditions such
podiatrist.
as calcaneal exostosis (bony spurs), tendocalcaneal
bursitis and plantar fasciitis.
• Diffuse tenderness under the metatarsal heads may
be a sign of Morton’s neuroma. This is a condition The hindfoot and forefoot
characterised by inflammation and pain around the As above, observe the position of the whole foot. Correct
third and fourth digital nerves. Pain is reproduced alignment is observed if the hindfoot and forefoot are in
on squeezing the medial and lateral sides of the line and perpendicular to the floor (Figure 11.58). Forefoot
forefoot together.
• Diffuse tenderness and swelling on both the plantar
and dorsal surfaces of the forefoot is a common
finding in rheumatoid arthritis.
• Tenderness on the mid posterior aspect of the
calcaneus may be a sign of a calcaneus bursitis.
• Tenderness along the Achilles tendon may be a sign
of a sprain or tendonitis in the Achilles tendon.

Alignments
Observe the posture of the heel relative to the leg. The heel
and lower leg should be parallel and the calcaneus should
rest squarely on the ground. Note any postural misalign­
ment such as excessive supination or pronation. A
Excessive pronation may cause posteromedial shin
splints, plantar fasciitis, hallux valgus or Achilles tendoni­
tis. Excessive supination may cause anterolateral shin
splints, dropped first ray (metatarsal) or plantar fasciitis.
Note whether the heel is inverted or everted. Posteriorly,
the Achilles tendon and the calcaneus should be vertically
aligned. Calcaneal varus is observed as the calcaneus being
inverted relative to the leg; calcaneal valgus is observed if
the calcaneus is everted relative to the leg.
Is the foot splayed or flattened? This may be owing to
weakness of the intrinsic muscles and subsequent flatten­
ing of the longitudinal arch. Observe the posture of
the medial arch and assess its height in comparison with
the other. B
Note any wastage of the calf musculature. Compare
both sides. Measure the circumference of the leg with a Figure 11.58  Alignment of the right leg and hindfoot:
tape measure at specified points below the patella. (a) calcaneal varus; (b) normal.

247
 Tidy’s physiotherapy

varus is observed if the first toe is superior to the lateral

toes. Forefoot valgus is observed if the fifth toe is superior
to the medial toes.

The toes
Look for:
• clawing (hyperextension of the metatarsophalangeal
joints and flexion of the other phalanges);
• mallet toe (flexion of the distal interphalangeal
joints);
• hammer toe (hyperextension of the
metatarsophalangeal and flexion of the proximal
interphalangeal joints);
• hallux valgus (lateral deviation of the first
interphalangeal joint); Figure 11.59  Measurement of ankle plantar flexion/
• hallux rigidus (stiffness of the first interphalangeal dorsiflexion.
joint).

Functional activities Definition

Assess the patient’s ability to stand on heels, toes, and the
inner and outer borders of the feet. Test the patient’s pro­
prioception. This may be performed with the patient
standing on one leg or on a wobble board, with the eyes
open and then closed. To make this more difficult the
patient can catch and throw a ball while trying to maintain
balance. Balance on the unaffected leg is assessed and then
compared with the affected side. Also, when appropriate,
test the patient’s ability to hop, squat and jump, noting
any stiffness or pain response.
Movements
Active movements
Ankle joint
The patient is in supine or sitting. Measure plantar and
dorsiflexion. Movement occurring at the tarsal joints is
easily mistaken for movement at the ankle, and vice versa.
Note pain or stiffness compared with the other side. Over­
pressure the movement if it is full range and pain-free.
The axis of the goniometer is placed 15 mm inferior to
the lateral malleolus. The static arm should be parallel to
the fibula. The dynamic arm should be parallel to the long
axis of the fifth metatarsal (Figure 11.59).
• Normal range of plantar flexion is approximately
50–55 degrees.
• Normal range of dorsiflexion is approximately 10–15
degrees.
Note that the knee needs to be in slight flexion if
full dorsiflexion is to be achieved. This takes the stretch
off the gastrocnemius.
Subtalar and midtarsal joints
In the normal foot, 80% inversion and eversion occurs at
the subtalar joint. Most of the remainder occurs at the
Inversion is the movement whereby the soles of the feet
face inwards towards one another. Eversion is the
movement whereby they face outwards.
midtarsal joints, with a little at the tarsometatarsal joints.
Determine the range by percentage of the abnormal to the
normal. Test:
• combined inversion and adduction (supination);
• combined eversion and abduction (pronation).
Toe movements
Observe flexion and extension at all the toes and compare
with the opposite side.
Passive movements
All the movements measured actively can be measured
and tested passively. Note any difference between active
and passive ranges, and identify possible reasons for
discrepancies.
Muscle strength
The dorsiflexors, plantarflexors, invertors and evertors are
tested by isometric and isotonic resisted movements.
Assess any weakness or pain elicited at any part of the
range.
Ligament tests
Lateral ligament stress test. The patient lies supine and the
physiotherapist grasps the heel and passively inverts the
foot, feeling for any opening at the lateral side of the foot
(Figure 11.60). A positive test may reveal increased inver­
sion movement, a sulcus dimple on the lateral side of the
foot or a pain response.

248
 Musculoskeletal assessment Chapter 11

Figure 11.60  Passive inversion of the plantar-flexed foot to Figure 11.61  Anteroposterior glide at the inferior tibiofibular
test the anterior talofibular ligament. joint.

To differentiate between the three bands of the lateral

ligaments, the test should be performed in:
• plantar flexion and inversion to strain the anterior
band;
• inversion only to strain the calcaneofibular band;
• a combination of dorsiflexion and inversion to strain
the posterior band.
Medial ligament stress test. The patient lies supine and the
physiotherapist grasps the heel and passively everts the
foot. A positive test may reveal increased movement of
eversion compared with the other side and/or may elicit
a pain response.
Anterior draw test at the ankle. This detects the integrity
and stability of the anterior talofibular and calcaneofibular
components of the lateral ankle ligaments. The patient lies Figure 11.62  Thompson’s test of the right calf. Slight
plantar flexion of the ankle suggests an intact Achilles
supine. The physiotherapist stabilises the distal leg, grasps
tendon.
around the talus and pulls it forwards. A positive test
reveals an anterior displacement of the talus in the mortise
of the lower end of the tibia and fibula, and suggests major
lateral ligament disruption. Observe for laxity, an audible
‘clunk’, or the presence of a lateral suction dimple.

Test yourself
Accessory movements (Maitland 2001)
Inferior tibiofibular joint Match these five scenarios to the likely pathology.
1. One ankle keeps giving way and feels unstable. There
Perform posteroanterior and anteroposterior glides
is poor proprioception on one leg.
(Figure 11.61).
2. There is pain in the plantar aspect of the heel on
Ankle joint weight-bearing or toe extension.
3. There is pain under the medial malleolus that
Perform:
increases on resisted inversion.
• posteroanterior and anteroposterior glides; 4. There is longstanding, insidious pain and stiffness in
• longitudinal movement cephalad and caudad; the ankle that increases on weight-bearing.
• medial and lateral rotation. 5. The patient has a history of an inversion strain
combined with swelling and bruising under the lateral
Subtalar joint malleolus.
Perform medial and lateral glides.

249
 Tidy’s physiotherapy

Metatarsophalangeal and interphalangeal joints
Perform:
• posteroanterior and anteroposterior glides;
• rotations and distractions.
tendon or muscle is ruptured and the ankle will not
plantar flex. A palpable gap in the tendon or muscle belly
may sometimes be observed if the tendon is ruptured.
Following on from the objective assessment write up your
findings clearly and asterisk an objective marker.

Thompson’s squeeze test Answers

This tests the integrity of the gastrocnemius/soleus Achilles
tendon complex. With the patient prone, the physiothera­
pist squeezes the calf firmly just distal to its maximum
circumference (Figure 11.62). If the tendon is intact, the
foot will plantar-flex. A positive test will occur if the
(1) Lengthened lateral ligaments. (2) Plantar fasciitis.
(3) Tendonitis of tibialis posterior. (4) Osteoarthritis of
the ankle. (5) Lateral ligament sprain.

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 Chapter
The physiotherapy management
of inflammation, healing and repair
Janette Grey and Gillian Rawlinson
INTRODUCTION
This chapter will introduce the reader to the processes
involved in inflammation and tissue healing and repair,
as well as discussing physiotherapeutic interventions that
may be used to facilitate this process. The healing and
repair process that occurs in response to tissue injury can,
in broad terms, be described as a continuum of events that
comprises of four stages: bleeding, inflammation, prolif-
eration and remodelling.
These stages are not mutually exclusive and will overlap
considerably, depending on the nature of the injury and
the individual. However, for the purpose of this chapter,
these four stages will be considered in sequence as under-
pinning a return to normal homeostasis and to normal
function.
Clinical note
The inflammatory and tissue repair processes are
fundamental to many pathologies and injuries that are
treated by physiotherapists. The treatment of the
inflammation itself may be directly affected by
physiotherapy modalities or may need to be treated
primarily through drug and medical intervention. For
example, the inflammation of the bronchioles in an acute
exacerbation of asthma would be managed medically
with corticosteroids.
Although inflammation and tissue repair are not exclu-
sive to the musculoskeletal system it is in this system that
the physiotherapist most closely works to influence these
processes. This chapter will, therefore, focus on the
12 
sequence of events following soft tissue injury and its
physiotherapeutic management. The aims of the chapter
are as follows:
• to identify the aims of physiotherapy and how they
change throughout the continuum of tissue healing
and repair;
• to provide the reader with specific physiotherapy
examples of managing inflammation and repair;
• to develop the reader’s ability to clinically reason
the use of core physiotherapy modalities in the
management of tissue healing and repair;
• to identify where research evidence underpins
practice.
In order to clinically reason an appropriate physiother-
apeutic approach to treatment for an individual’s problem,
many factors need to be considered. The physiotherapist
needs to understand the anatomical and histological
make-up of the different tissues, as well as the normal
processes of inflammation, tissue healing and repair. It is
also vital that the physiotherapist has excellent assessment
and clinical reasoning skills in order to correctly identify
the tissues involved and the underlying pathology. The
clinical reasoning process also requires the physiothera-
pist to consider psychological and social factors, which
will undoubtedly influence an individual’s recovery and
rehabilitation.
These factors may significantly alter the approach a cli-
nician takes and maybe even exclude certain treatment
modalities that would normally be considered. It is this
individualised, holistic and evidence-based approach that
makes the physiotherapist an invaluable contributor to the
patient’s optimal recovery from disease or injury. The clini-
cal reasoning process is illustrated in Figure 12.1.
Two case studies will be presented to illustrate the
suggested application of physiotherapy interventions
discussed in relation to the healing and repair processes.
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 Tidy’s physiotherapy

Anatomy
Therapeutic effects
of treatment Environment
modalities

Physiology Pathology

Patient

Psychology Histology

Kinesiology Biomechanics

Sociology

Figure 12.1  Factors influencing the clinical reasoning process for the management of patients’ tissue healing and repair.

THE CONTINUUM OF TISSUE

HEALING AND REPAIR
Bleeding
When any soft tissue is injured, be it through trauma,
injury, overuse or surgery, a natural sequence of events Inflammation
follows in order to repair the damaged tissue and restore
homeostasis and normal function.
This process starts with a short period of tissue bleed-
ing owing to the disruption of small blood vessels and
Proliferation
capillaries. Immediately following this period of bleeding
a complex cascade of biochemical events proceed, trigger-
ing an inflammatory reaction. The inflammatory process
initiates the proliferation of new tissue cells, which
eventually remodel with the aim of restoring normal
tissue function. This sequence of events is illustrated in Remodelling
Figure 12.2.
This sequence of events does not take on exact time­
scales and it is useful to think of this as a continuum
whereby each stage of healing will overlap with the next
Hours Days Weeks Months
depending on many factors, such as the severity and
nature of the injury, the patient’s age and tissue type and Figure 12.2  Phases of tissue repair. Reproduced with permission
what the individual does or not do in terms of movement, from Watson (2004) with permission.

254
 The physiotherapy management of inflammation, healing and repair
activity and intervention. In many cases these healing pro­
cesses occur without problems; however, several factors
can cause this process to be delayed or exaggerated, leading
to less than optimal tissue structure, pain and ultimately
reduced function.
For many years physiotherapists have utilised a
wide range of treatment modalities and interventions
with the intention of promoting healing and repair. The
main aim of using any physiotherapeutic modality or
intervention should be to facilitate and progress tissue
through this normal healing and repair continuum,
thus facilitating early recovery and return to maximum
function.
Soft tissue injury
When injury or trauma occurs producing forces necessary
to damage soft tissues it is important to consider what
happens to these tissues at a cellular level. The secondary
injury model described by Merrick (2002) considers there
to be two stages following tissue injury, namely the
primary and secondary injury response:
• the primary injury is considered to be the damage
to cells caused by the direct injury mechanism, be
that a crush, contusion or strain force. The cells
damaged by this mechanical force may have their
cell membranes disrupted causing a loss in
homeostasis and subsequent cell death. Many
types of tissue may be involved, including
Phases 1 and 2 of tissue healing and repair
PHASE 1: BLEEDING (0–10 HOURS)
This is a relatively short phase that will depend upon the
initial injury type, the tissues damaged and the severity of
injury. If there has been an injury to soft tissues some
degree of bleeding will occur. When capillaries and small
blood vessels sustain primary injury, blood will escape
into surrounding tissues and, depending on the location,
may gradually track distally as a result of gravity. The type
of tissue involved and the type of injury will determine
the degree of bleeding in terms of amount and duration.
If very vascular tissue is damaged (e.g. muscle) a larger
amount of bleeding will occur in comparison with less
vascular tissues, for example ligament and tendon. The
bleeding phase may only last a period of a few minutes or
hours, but in large muscle contusion injuries, for example,
bleeding may continue to a small degree for up to 24
hours (Watson 2004).
Chapter 12
ligament, tendon, muscle, nerve and connective
tissues;
• secondary injury is thought to be caused by
physiological responses to the initial primary injury.
This occurs to tissues at the periphery of the injury
to those cells not damaged by the primary injury. It
is hypothesised that this damage may occur by two
means. These are hypoxic (or maybe better described
as ischaemic) and enzymatic mechanisms.
Ischaemic mechanisms
There are several proposed causes of ischaemia (reduced
blood flow) to the damaged tissue, including haemorrhag-
ing from blood vessels, increased blood viscosity second-
ary to inflammatory responses and increased extravascular
pressure secondary to oedema. This reduced, or absent,
blood supply will deprive cells which may have survived
the primary injury of vital oxygen causing them to rely on
the anaerobic energy systems which only have a short
timescale (possibly up to six hours). If the ischaemia pro-
longs, many of these cells will subsequently die.
Enzymatic mechanisms
The lysosomes of those cells destroyed or damaged in the
primary stage will produce enzymes that may damage and
destroy neighbouring cells. This often occurs as a result of
damage to the cell membrane, which causes the cells to
swell and eventually die.
PHASE 2: INFLAMMATION (0–4 DAYS)
Inflammation is a complex biochemical and cellular
process which is still not fully understood. It can be trig-
gered by many factors other than injury, such as infection
and pathology.
Clinical note
When assessing bleeding it is also worth considering the
location of the injury, as this will affect where the
bleeding distributes. For example, with a tear of the
anterior cruciate ligament the bleeding will be
intracapsular in the knee and is unlikely to present as
obvious bleeding and bruising with discolouration but as
a tense swelling which, if aspirated, could be identified
as blood causing a haemarthrosis.
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 Tidy’s physiotherapy
Following an injury or pathological process there is
an immediate inflammatory response. Scott et al. (2004)
describe inflammation as a complex process that can
be viewed at four levels: clinical, physiological, cellular
and molecular, and suggest that it is the application
of clinical reasoning skills that allows us to define which
level is relevant in any given situation. Discussion of
the complex biochemical sequences involved in the
inflammatory process are beyond the scope of this chapter
– the reader is referred to the wealth of books which
discuss these biochemical and pathological aspects in
more detail.
The inflammatory response has been reported to last
for several days, or even weeks, but usually peaks around
2–3 days post-injury. During this inflammatory phase
there may well be several clinical features evident. These
include redness, swelling, pain and loss of function.
During inflammation there is primarily a vascular and
cellular response. The vascular response is a result of
chemical inflammatory mediators and also a neural effect
on the arterioles. There is an initial vasoconstriction that
lasts only a period of seconds, followed by a more pro-
longed vasodilation response. There is also an increase in
the permeability of the capillary walls allowing migration
of large plasma proteins into the interstitial space. This
alters the osmotic pressure in the tissue and exudate
will gather in the interstitial space causing swelling. As
cells migrate across the vessel wall into the interstitial
fluid this will become cellular exudate. This exudate will
contain mainly neutrophils initially and then lymphocytes
and monocytes as the inflammatory process progresses
(Mutsaers et al. 1997).
The cellular response is mediated and maintained by
chemical mediators, which results in altered cellular activ-
ity. These processes will eventually aid the removal of any
microorgansims and damaged tissue debris. Pain is caused
by both irritation of damaged nerve endings from these
chemical mediators and pressure on nocioceptors from
the increase in exudate.
Often, clinically, this inflammatory phase is seen as a
hindrance to the repair process and interventions that
have an anti-inflammatory action are often employed with
the aim of halting and slowing this process. It should be
Clinical note
There is some debate as to whether non-steroidal
anti-inflammatory drug (NSAID) therapy should be used
in soft tissue injury as it may slow down this phase of
tissue healing, thus slowing overall recovery. Alternatively,
the suggestion is that if it controls the inflammatory
response and prevents it becoming exaggerated or
prolonged this may, in fact, facilitate progression through
the healing continuum.
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noted, however, that inflammation is, in fact, a normal
response to injury and should be facilitated in order for
the patient to progress through the healing and repair
continuum.
Occasionally, individuals will develop a prolonged or
exaggerated inflammatory response that fails to resolve
within the normal timeframes. The mechanisms behind
the development of chronic inflammation are not yet fully
understood and are beyond the scope of this chapter.
PHYSIOTHERAPY INTERVENTIONS  
IN PHASES 1 AND 2 (0–72 HOURS
POST-INJURY)
When considering the physiotherapy approaches that we
can employ at these early stages of tissue injury, we must
consider the physiological processes occurring and the
aims and physiological responses to treatment.
When treating any patient with an acute injury, for
example a ligament sprain or a muscle contusion, the aims
of treatment must be decided in specific relation to the
individual, in order to plan treatment accordingly.
General physiotherapy aims of early
phase management (phases 1 and 2)
The aims are:
• to reduce pain;
• to limit and reduce inflammatory exudates;
• to reduce metabolic demands of tissue;
• to protect newly damaged tissue from further injury;
• to protect the newly-forming tissue from disruption;
• to promote new tissue growth and fibre
realignment;
• to maintain general levels of cardiovascular and
musculoskeletal fitness/activity.
The PRICE principles
PRICE is a mnemonic for the principal interventions com-
monly used in the immediate early stages following tissue
injury. PRICE stands for :
• protection;
• rest;
• ice;
• compression;
• elevation.
These interventions together are applied in principle to
address the seven aims of early phase tissue injury and
healing management. These interventions are discussed
below. The reader is also referred to the guidelines written
in conjunction with the Association of Chartered Physio-
therapists in Sports Medicine (ACPSM), on the immediate
 The physiotherapy management of inflammation, healing and repair
management of soft tissue injury using the PRICE princi-
ples (Bleakley et al. 2010).
Protection
When soft tissue injury has just occurred it is important to
protect tissues from further damage, both chemical and
mechanical (secondary), and also to protect newly forming
collagen fibrils in the following days. Measures to prevent
tissues from this further mechanical damage are generally
described as protective modalities and may include treat-
ments such as strapping, use of crutches, slings and braces,
and modification of exercises and movements.
Strapping
There are various techniques of strapping that can be
applied in the early stages to protect injured areas from
further damage while allowing the individual to continue
with other activities and exercise. When deciding on the
use of a strapping technique it is important to consider
the structure(s) damaged and the movement(s) which are
likely to stress the damaged area. Strapping can be applied
in a manner to allow maximal movement while protecting
from the movement(s) likely to cause further damage.
Again, this emphasises why it is essential that the physio-
therapist has a detailed knowledge of anatomy and human
movement when treating injured and healing tissues.
It is important to remember that any strapping applied
in these early stages must be able to accommodate a
change in size or circumference because of swelling, to
prevent compromise of the circulatory system. Often
compression bandaging (as discussed below) will alone
restrict movement and may be sufficient to protect from
unwanted movement. Alternatively, additional specific
strapping may be applied to reinforce and prevent specific
movement patterns.
Clinical note
If someone has injured their anterior talofibular ligament
in their ankle it will be necessary in these early stages to
protect this structure from stresses into inversion and
plantar flexion while allowing eversion and dorsiflexion
movements. This can be achieved through accurate
strapping.
Strapping needs to be reapplied regularly and also needs
to be monitored regularly to ensure its safety and effective-
ness. The physiotherapist will need to consider if the
patient is able to reapply strapping independently or not,
which may influence its use if the patient has limited
contact with the physiotherapist.
The patient must also understand the limitations of the
strapping. Some individuals may feel able to continue
Chapter 12
with all activities while wearing strapping when, in fact,
this could be detrimental to the injured and surrounding
tissues.
Other methods of protecting injured
and healing tissues
The main factors affecting the physiotherapist’s decisions
to use a protective device are the individual’s needs, the
extent and nature of the tissue injury and the location
of the damage. Devices such as slings may serve the
purpose of elevating the limb while also having a protec-
tive role.
Clinical note
In the case of a patient having had a fasciectomy for
release of Dupuytren’s contracture, a splint is required
immediately postoperatively to put the newly cut
tissues under stress and encourage lengthening
in order to prevent newly forming tissue from
re-tightening, thus causing continued reduced function
of the hand.
Walking aids
Walking aids will need to be provided if gait is altered.
Also, partial weight-bearing may be advised in the early
phases to protect damaged tissues, which will be stressed
excessively during weight-bearing. Remember that the
main aim of prescribing a walking aid is to promote a
normal gait pattern within the limits of any restricted
weight-bearing. This is essential to allow normal move-
ment patterns of adjacent joints and body segments and
to minimise any secondary problems.
Rest
Rest, in this context, usually refers to some form of relative
rest in terms of general movement and activity to reduce
metabolic demands and, hence, further secondary chemi-
cal damage to tissues. Rest from specific activities (relative
rest) will also go some way towards protecting damaged
and newly forming tissue.
However, it must be remembered that excessive unload-
ing of the structures and prolonged rest can do harm
to the patient so must be balanced carefully with appropri-
ate activity (Bleakley et al. 2010). Therefore, the physio­
therapist needs to carefully balance these protection
and rest aims with those of promoting movement in
order to maintain normal function of adjacent joints
and structures.
In the very early stages (0–48 hours) when the tissues
are still likely to be bleeding and the inflammatory process
will be underway, the patient should be encouraged to rest
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 Tidy’s physiotherapy
the injured area fully to prevent increased bleeding and
inflammatory response.
As this very early phase ends (around 48 hours),
very gentle movement is needed to help improve circula-
tion and removal of waste products, and to provide the
necessary stresses for the correct alignment and orienta-
tion of newly forming tissue fibres. Both local and sys-
temic exercise can assist in this process through changes
in haemodynamics and lymphatic function (Bleakley
et al. 2010).
This trade off between rest and activity can often form
conflicting advice for the patient – the physiotherapist
needs to ensure that advice regarding movement and activ-
ity is clearly understood by the patient for maximum
benefit.
Again, it is worth remembering at this stage that effec-
tive physiotherapy practice is underpinned by firm clinical
reasoning where individuals’ physical, social and psycho-
logical needs, their tissue damage and stage of healing are
all considered in light of considered best practice in that
treatment area.
Clinical note
It is essential with both elite and recreational athletes
that they are advised and managed in terms of
maintaining cardiovascular fitness and musculoskeletal
fitness. This may require the individual to do a reduced
or non-weight-bearing activity/programme such as
exercise in water or reduced impact activity, or activities
that do not involve the affected area. Remember,
athletes may be eager to restart activity prematurely
and the physiotherapist must take an active role
in ensuring the patient fully understands the implications
of all activities on the likely outcome of their injury/
problem.
Cryotherapy (ice therapy)
Cryotherapy is defined as the use of cold and cooling
agents used for therapeutic benefits, and has long been
considered an important part of early tissue injury man-
agement. There are various methods of cooling tissues
including the application of crushed ice, ice/gel packs,
cold compressive devices and ice submersion. The com-
parative effects of these have not been fully investigated
and the method of application is still mainly determined
by the nature of the injury, equipment variability and
therapist preference. The use of cryotherapy has not been
fully investigated in terms of scientific research and much
of physiotherapy practice in this area is based upon expe-
riential evidence.
258
The primary reason for applying ice in the immediate
early injury management is to cool the affected tissues,
hence reducing the metabolic demands of the neigh­
bouring cells. This should enable more cells to survive
the ischaemic phase, thus minimising secondary tissue
damage. It is suggested that to maximise the therapeutic
effects of cryotherapy, an optimal tissue temperature
reduction of 10–15° is required (MacAuley 2001). If the
application of cryotherapy can reduce the number of cells
damaged overall, the healing and repair process will be
quicker, hence speeding up return to function.
Traditionally, the application of cryotherapy may have
been thought to induce vasoconstriction of the small
blood vessels, thus reducing blood supply to the area and
hence causing increased ischaemia to the tissues and
further secondary damage as initially described by Knight
(1989). Merrick (2002) suggests that the secondary injury
model described above now better describes the effects of
cryotherapy. It must be noted, however, that there is very
little conclusive evidence that investigates how cryother-
apy affects the metabolic processes and whether it can
influence inflammation (Bleakley et al. 2010).
The duration, application and frequency of cooling to
achieve maximum therapeutic benefits has not yet been
determined scientifically, yet these factors will greatly
affect the degree of tissue cooling. Not all modes of
cooling are equally effective; however, crushed ice provides
effective cooling and is probably the safest (Bleakley et al.
2010). Subcutaneous fat covering will insulate deeper
tissues and thus limit cooling significantly. Therefore,
some areas may require slightly longer cooling times.
Other important points are that the cold application
should cover the whole area of injured tissue and a damp
towel should be placed between the cooling agent and the
skin to avoid skin and tissue damage. Using a thick, dry
protective layer is likely to significantly reduce the cooling
effects. It is also worth noting that research suggests that
deep tissue temperature stays the same or continues to
cool for up to 10 minutes following removal of an ice pack
(Bleakley et al. 2010).
The use of cryotherapy is widespread in practice and it
is generally accepted that it is a very safe and easy-to-use
modality, making it very popular. However, it is very
important to remember that direct cold application can
cause what are commonly described as ‘ice burns’. This
may be described as superficial frostbite and the symp-
toms are similar to a thermal burn with pain, redness,
swelling and blistering. It has been highlighted recently
that ice burns are probably under-reported and are much
more common than was previously thought. Remember to
exercise caution when applying cryotherapy and reassess the
patient regularly. If the patient has reduced sensation, or
nerve injury is suspected, extreme caution must be used
and it is advisable to avoid cryotherapy until this has been
fully assessed.
 The physiotherapy management of inflammation, healing and repair
Clinical note
When deciding on the dosage of cryotherapy application
always consider:
• the size of the injury;
• the depth of the tissues injured and subcutaneous fat
depth.
Always check sensation and monitor the skin regularly
for evidence of ice burns. Placing a damp towel between
the ice pack and skin should avoid damage, as should
the use of a cold compression device.
Compression
Compression of the affected tissue and adjacent areas can
also be used in the early phases to reduce exudate, protect
tissues and possibly reduce pain.
The theory behind the application of compression is
that the hydrostatic pressure of the interstitial fluid is
raised, thus pushing fluid back into the lymph vessels and
capillaries, and reducing the amount of fluid that can seep
out into surrounding tissues (Rucinski et al. 1991). Exter-
nal compression through the application of an elastic
wrap can stop bleeding, inhibit seepage into underlying
tissue spaces and help disperse excess fluid (Thorsson
et al. 1997).
Compression can be applied using a tubular bandage or
some form of elasticated bandage strapping which may be
adhesive or non-adhesive. It is vital that any product used
is elasticated in order to accommodate changes in size or
circumference of the body part without compromising
circulation.
Compression can be used in direct conjunction with
cryotherapy in the form of an ice compression device, for
example Cryocuff, which allows simultaneous cooling
and compression of tissues. If this method is not used
there is generally some trade-off in terms of using cryo-
therapy and compression. It is not usually possible to
sufficiently cool tissues through a compression bandage;
therefore, intermittent use of cooling methods may be
applied between compression.
Unfortunately, there are very few studies which look
specifically at the effects of applying compression alone in
acute soft tissue injury and, again, much of contemporary
practice is based upon experiential evidence and consen-
sus opinion (Bleakley et al. 2010).
Elevation
Another treatment method aimed at reducing bleeding,
swelling and, thus, pain in acutely injured soft tissues is
elevation. Some studies have suggested that elevating the
injured limb above the level of the heart reduces inter-
arterial pressure and enhances draining of extravascular
Chapter 12
Clinical note
When applying compression you will need to consider
the following points (Kerr et al. 1999).
1. Apply compression as soon as possible after injury.
2. Always apply compression from distally to proximally.
3. Where possible, apply the compression a minimum
of six inches above and below the affected area.
4. Always follow the manufacturer’s instructions where
available.
5. Do not apply compressive materials with the material
at full stretch.
6. Ensure consistent overlap (half to two-thirds) of
previous turn of compressive material.
7. Apply turns in a spiral fashion, never in a
circumferential pattern.
8. Use protective padding, such as gauze, underwrap,
foam, etc., over vulnerable areas such as superficial
tendons and bony prominences.
9. Do not apply elasticated leggings in the lying
position or in association with elevation.
10. Remove and reapply if the pressure appears not to
be uniform or if the patient complains of discomfort.
Otherwise, reapply within 24 hours.
11. Continue compression for first 48 hours when not
lying down.
12. Always check the distal areas following compression
to check for diminished circulation, i.e. colour
changes or cold.
fluid away from the area; however, scientific evidence sup-
porting this is minimal.
It is common practice to combine cryotherapy and com-
pression with elevation in order to minimise swelling and
gathering of interstitial fluid. However, continuously ele-
vating the limb above the level of the heart is often imprac-
tical (especially if it is the lower limb) and may even
compromise vascular supply to the body part if combined
with compression. It may be more appropriate to advise
the patient to elevate the affected limb intermittently
during the day when possible and to remove compression
at this time.
In the early stages a large amount of swelling is
often evident if an individual with lower limb injury
(particularly distal injury), stands and walks for a long
time with the injured part in a dependent position. It
would seem logical that if patients are advised to mini-
mise the amount of standing and walking they do,
and elevate the limb from the earliest point, this may
reduce the accumulation of fluid which can quite quickly
become thickened and fibrous owing to its high protein
content. When an individual does stand and walk around
then the use of compression would seem sensible to
continue to minimise the accumulation of exudate in
259
 Tidy’s physiotherapy
the surrounding tissues. One practical point to remember
when advising elevation is to support the limb ade-
quately during elevation through the use of pillows or
a sling.
Again, evidence underpinning the use of elevation to
promote healing and recovery is lacking and research often
shows that improvements in swelling are short-lived and
swelling often recurs when resuming gravity-dependent
positions (Bleakley et al. 2010).
First-line management
Increasingly in modern physiotherapy practice the physi-
otherapist will be the first line of medical assessment,
management and advice. This may occur, for example, in
the sporting environment, in private practice or via direct
access services. These roles require the physiotherapist to
have excellent assessment skills and experience, and the
understanding of differential diagnoses and indications
for onward referral. Several guidelines are in place to aid
clinicians in managing and diagnosing injuries, and using
investigations such as radiology. Physiotherapists should
be aware of these guidelines and implement them appro-
priately in order to promote best practice. For example,
physiotherapists working in these settings should be
familiar with the Ottawa guidelines for ankle injuries
(Bachmann et al. 2003), which guide clinicians on
when to X-ray the ankle to rule out fracture.
Applying the PRICE principles   When deciding how long to continue to apply these
in practice
Having discussed the elements of the PRICE principles it
is evident that there are sometimes conflicting demands
and that it is often not possible or, indeed, appropriate
to employ all five principles simultaneously. As discussed
previously, the research evidence underpinning these
interventions is insufficient and much of everyday practice
is based upon historical approaches and consensus
opinion (Bleakley et al. 2010). It is therefore important to
consider this and the physiological processes occurring in
the tissues when rationalising a treatment plan for an
individual patient. It is also important to make realistic
and reasoned treatment decisions considering all bio-
psychosocial factors. This can be illustrated through the
use of the case studies in this chapter.
Severity of injury and progression
through the healing continuum
The speed of progress and recovery of those who have
sustained soft tissue injury will vary depending on a large
number of factors. These include the type, severity and
location of injury, the individual’s tissue type and response
to injury, and many extrinsic factors, such as their exposure
to appropriate treatment and advice in the immediate
260
stages, and any other psychosocial factors. For example, a
minimal grade I ligament injury effectively managed in the
early stages may move very quickly through the contin-
uum of tissue injury to repair and remodelling within a
few weeks, whereas major tissue injury induced through
trauma or surgery may require a much longer process.
Those individuals not having sought, or followed, advice
and treatment in the early stages are more likely to develop
problems such as chronic swelling, loss of range of move-
ment and function in injured and adjacent structures, and
may even have compromised the formation of appropriate
new tissue.
In view of this it is desirable that individuals seek
early advice from an appropriately trained professional
and that they fully understand the advice and treatment
approaches taken. Often, many of the treatment modali-
ties discussed so far can be implemented by a patient
independently at home and the frequency and accuracy
by which they do this will have a large impact on their
recovery and progress. It should, therefore, be ensured
that physiotherapy intervention is focussed on establish-
ing that the patient fully understands the advice and treat-
ment approaches that will be implemented at home,
especially if the frequency of physiotherapy contact will
be limited. If the patient does not fully understand the
advice given and instructions regarding their activities at
home then any benefit gained from a physiotherapy treat-
ment session will be undermined by the patient’s behav-
iour in the intervening period.
principles consideration of the severity and size of the
injured area is required. Despite common descriptions of
grades of muscle and ligament injury being used, it is
impossible to determine this accurately without radiologi-
cal investigation such as ultrasound imaging. This is an
area of increasing research; however, its clinical relevance
in the management of muscle injuries is still under debate.
Without the aid of valid and reliable imaging it would
seem sensible to use the patient’s level of pain and pos-
sible gentle palpation to indicate the size of injury as
indicators of when to progress rehabilitation.
As discussed earlier, it is often suggested to consider
beginning early movement of the injured part at around
72 hours post-injury as initial pain is reducing, and pro-
gressing to gradually achieve full range of movement of
the affected tissues before moving on to increase normal
muscle power, strength, timing and proprioceptive control
in light of the patient’s individual needs and abilities. In
the early stages, acute pain is often a sign of further tissue
injury and bleeding; thus, activity and movement of the
injured area should be discouraged. However, as the con-
tinuum progresses, pain is often secondary to problems
such as joint stiffness and lack of strength and control, and
needs to be respected but not seen as a barrier to progress-
ing rehabilitation. This will be discussed in detail in the
following sections.
 The physiotherapy management of inflammation, healing and repair
Phases 3 and 4: proliferation and remodelling
This section of the chapter deals specifically with the man-
agement of patients in the later stage of the healing and
repair process. That is, beyond the initial bleeding and
inflammation stages (the first 1–3 days following injury).
Watson (2004) refers to these stages as the stages of pro-
liferation and remodelling. The physiotherapeutic man-
agement of patients in these stages of the healing and
repair process is still driven by the utilisation of physio-
therapeutic measures which compliment, support and
encourage these normal processes and therefore promote
and facilitate repair. The underpinning reasoning behind
physiotherapy in these stages of healing relates to the
plastic properties of human tissue.
PLASTICITY IN HUMAN TISSUE
Plasticity refers to a quality associated with being plastic,
malleable, and capable of being shaped or formed
(OED 2007). Although the term plasticity tends to be
most frequently applied in the field of neurology it is
important to recognise that it is a characteristic of all
human tissue. Human tissues have the capacity to adapt
to the nature and extent of the forces applied to them. For
example, if we consider the practice of lifting weights. Over
a period of time, within a progressive lifting programme,
an individual will be able to progressively lift larger
weights. The skeletal muscles and tendons loaded by
lifting weights adapt over time as the individual pro­
gressively lifts more weight. These adaptations affect all
components of the musculotendinous apparatus. The con-
tractile component of the muscle gets larger and stronger
(Kraemer and Ratamess, 2004) and capable of producing
increased force.
In parallel with this process the non-contractile compo-
nents get correspondingly stronger and thicker to accom-
modate the extra loading (Benjamin 2002). In addition,
adaptations occur at the interface between the tendon and
the bone so that the bony prominences also develop to
withstand the increased force exerted. Consider an indi-
vidual who suddenly lifts a weight or engages in an activity
where the force generated with the musculotendinous
apparatus exceeds that which the muscle, tendon or bone
can withstand. In this situation the tissue fails to with-
stand the force applied and injury occurs. For example,
excessive load generated in the quadriceps muscle may
lead to muscle damage, patellar tendon damage or avul-
sion fracture of the tibial tubercle.
Human tissues undergo reversal of these adaptations
during the periods of immobilisation or reduced activity
which occur frequently following trauma. In these situa-
tions the effect of immobilisation causes the reverse of the
Chapter 12
processes identified above. This reduces the ability of the
damaged tissues to withstand loading. Physiotherapeutic
management of these patients focusses on trying to restore
the affected tissues’ capacity to withstand normal loading
therefore enabling the individual to return to normal func-
tion. It is important to remember that these soft tissue
adaptation processes occur in both the injured and the
uninjured tissues.
Physiotherapeutic approaches are therefore fundamen-
tally aimed at capitalising on this plastic property of
human tissue so that therapy works alongside, and
enhances, the normal healing and repair processes.
Clinical note
A patient who sustains a severe second degree injury
to the lateral ligament complex at the ankle and who
subsequently has to non-weight-bear will experience
soft tissue changes throughout the non-weight-bearing
leg, not just in the tissues directly affected by the
trauma.
FACTORS INFLUENCING THE RATE  
OF HEALING IN THE STAGES OF
PROLIFERATION AND REMODELLING
An important consideration is that the processes of tissue
proliferation and remodelling take place over significant
periods of time (Watson 2004). The period of time for
the completion of these pathophysiological processes can
run into years and is dependent on a number of factors
including:
• severity of initial trauma, e.g. a severe second-degree
ligament sprain of the lateral ligament complex at
the ankle will have a more prolonged proliferation
and remodelling period than a first degree ligament
sprain affecting the same structure;
• early management where the approach taken has
laid the necessary foundations for proliferation and
repair, e.g. an appropriate approach has been taken
to rest/protect traumatised tissues (see earlier
sections in this chapter). This has the potential to
reduce the onset of chronic inflammation where an
agent is responsible for the ongoing irritation of an
injury and therefore perpetuates the period of the
stages of bleeding and inflammation;
• tissue vascularity, e.g. skeletal muscle, which is highly
vascular, has more potential for repair than a
relatively avascular tendon;
261
 Tidy’s physiotherapy
• age, e.g. a similar grade of injury is likely to take
longer in the repair process in an older individual
than one who is younger (Myer 2000);
• nutrition – adequate nutrition (also related to blood
flow) is required for healing to take place;
• medication, e.g. NSAIDs and steroidal drugs slow
down proliferation and remodelling processes;
• temperature;
• biochemical factors;
• appropriate loading of healing tissue during
rehabilitation.
It is very important that the physiotherapist has a depth
of understanding of the pathophysiological processes
involved in proliferation and remodelling, as well as the
clinical reasoning skills required to make the appropriate
professional decisions. In addition to this knowledge, the
ability to apply this knowledge of the clinical effects of a
number of physiotherapeutic treatment modalities, as well
as the psychological and sociological theory in order that
treatments are effective, is also required. In this section,
short case studies will be used to illustrate the main
points.
Evans (1980) simplified these processes in his ‘graphs
of hours’, ‘graphs of days’ and ‘graphs of months’. Although
dated, this timeframe serves as a useful timeline against
which to make judgements about physiotherapy ap­­
proaches. An understanding of the timeframes involved
in this continuum enables the physiotherapist to coordi-
nate his/her approach to treatment and capitalise on the
normal healing processes while ensuring that physiother-
apy intervention does not induce further trauma and
therefore delay healing and repair.
PHASE 3: TISSUE PROLIFERATION
(FIBROUS REPAIR) (1–10+ DAYS
POST-INJURY)
Pathophysiology
Cellular processes during this stage include:
• ongoing phagocytosis;
• angiogenesis (formation of new blood vessels);
• proliferation of fibroblasts;
• production of collagen fibres (initially these are
produced in an unordered and random fashion);
• absorption of inflammatory exudate.
As the initial processes of inflammation begin to lessen,
the inflammatory exudate begins to be absorbed. This
leads to a decrease in swelling. Pain is reduced as a result.
An increase in swelling during this stage is usually indica-
tive of a more severe injury. Alternatively, this may be a
result of inappropriate early management, for example a
patient who has sustained a severe second-degree sprain
262
of the lateral ligament complex at the ankle joint returns
to full weight-bearing activity before the injured tissue
strength has developed to a point where it is capable
of withstanding the forces that walking demands of it.
Tissue proliferation begins to occur as early as 24 hours
after trauma. This proliferation begins the stage of fibrous
repair, which usually involves the production of scar
(collagen) material. The nature of the tissue, which is
produced in the proliferation phase, is dependent on
which elements of the tissues are damaged initially. If the
cellular framework (satellite cells) is not damaged then
regeneration of these cells may be possible. If the cellular
framework (satellite cells) is destroyed then the tissue is
replaced by scar tissue. In addition, if the cells damaged
have no capacity to regenerate because they are deemed to
be permanent cells, for example nerve cell bodies and
cardiac muscle, then scarring definitely occurs. Scar tissue
is a non-differentiated form of fibrous tissue that may
develop some properties of the original tissue but will not
function in the same way as the normal tissue would. By
2–3 weeks after the injury the majority of the scar tissue
is in place. After this time, the rate of proliferation dimin-
ishes but may continue for several months following the
injury. There is no hard and fast rule about exactly when
this occurs, as the timeframe will vary in accordance with
the factors that influence repair identified at the beginning
of this section, for example it will occur earlier in vascular
tissues.
Around 3–4 days following trauma the process of cell
death will be complete and this means that the physio-
therapist can assess the injury more objectively. At this
stage the risk of aggravating/increasing the trauma or iden-
tifying false-positive findings because the patient’s pain is
masking the real symptoms is reduced. It is at this point
that the physiotherapist can begin to use therapeutic tech-
niques that promote an increase in circulation and tissue
temperature without fear of inducing further tissue damage
or further bleeding.
GENERAL PHYSIOTHERAPY AIMS  
IN THE TISSUE PROLIFERATION
STAGE – PHASE 3
At this stage in the repair process the aims of physiother-
apy may include the following:
• decreasing pain;
• decreasing swelling;
• decreasing local temperature;
• preventing further trauma;
• protecting new tissue;
• increasing range of movement;
• maintaining/increasing muscle strength/timing and
control;
 The physiotherapy management of inflammation, healing and repair
• preventing soft tissue adaptation in non-injured
tissues;
• improving function.
The above represents an approach to a treatment that is
impairment focussed and biomedical in approach. It is
essential that this generic approach be modified to reflect
the individual nuances of each patient and their individ-
ual and specific psychosocial needs. For example, increas-
ing range of movement and improving function could be
joined into one function-specific, patient-centred aim, for
example ‘to able to tie own shoelaces’.
Physiotherapy in the tissue
proliferation stage (1–10+ days
post-injury)
In this tissue proliferation stage physiotherapeutic treat-
ment approaches are aimed at the achievement of the
goals as identified above by influencing the pathophysio-
logical processes involved in this stage of healing and
repair. While approaches to physiotherapy to address the
first four aims have largely been covered in the earlier parts
of this chapter when considering the management of the
bleeding and inflammation stages of the healing and
repair continuum these are still worthy of a mention here.
In order to reduce pain the injury may require a degree of
ongoing protection, such as limiting movement to that
which is pain free. However, the degree of protection will
slowly be reduced throughout this stage.
Use of cryotherapy at this stage
Cryotherapy can continue to be utilised if the area injured
continues to have an elevated temperature. However, it is
likely that this will probably only be required at this
stage in more severe injuries. Often at this stage the physi-
otherapist might choose to apply cryotherapy at the con-
clusion of a treatment session. The clinical reasoning
underpinning this is that during this stage the potential
to cause minor bleeding and inflammation as a result of
treatment is high owing to the frail and vulnerable nature
of the newly developing tissue. Cryotherapy applied at
the end of treatment can potentially minimise the risk of
this occurring.
Prescribing activity and exercise   developed collagen tissue begins to accelerate thereby
in the proliferative stage
During this proliferative stage the main input by the physi-
otherapist is to encourage a graded return to exercise and
activity. This is achieved through the prescription of a
specific exercise programme tailored to each individual
patient’s needs. This type of approach that involves active
involvement of the patient is valuable as it promotes
Chapter 12
patient empowerment and prevents the patient from
taking a passive approach to treatment.
The aims of increasing range of movement, maintaining/
increasing muscle strength/timing/control, preventing soft
tissue adaptation in non-injured tissues and improving
function are all best achieved through application of
graded exercise and activity. Inevitably, function will be
improved to some extent by activity to increase range,
increase muscle strength and prevent soft tissue adapta-
tion. However, it is important that functional activities
that are specifically pertinent to the individual are targeted
specifically within an individual’s treatment programme
as early as possible, for example increasing ankle range of
movement is unlikely to produce a direct improvement
in walking performance without a specific rehabilitation
activity aimed at improving walking. The primary empha-
sis of activity and exercise in this proliferative phase is to
increase range of joint movement.
Grading the level of activity
Ensuring that any activity undertaken by the patient early
in the proliferative stage is completed within pain-free
limits provides a mechanism to protect newly developing
tissues and prevent further secondary damage to those
tissues initially traumatised at the time of the injury. It is
sensible throughout this proliferative stage of healing and
repair to use the patient pain report during activity as an
indicator of appropriate levels of activity and exercise. As
a rule, any activity or exercise prescribed in the prolifera-
tive phase that provokes pain, which could be classified
with a high SIN (pain severity, irritability and nature)
factor should be avoided.
From around the second day post-injury, fibroblasts
are increasingly prevalent around the site of the trauma.
These are the precursors to the formation of new fibrous
tissue that will enable the healing process. In the prolif-
erative phase, it is inappropriate to do aggressive activi-
ties or exercises of the areas directly affected by the
trauma, as this will only serve to further damage the
newly developing tissue. The use of gentle, active move-
ments controlled by the patient within the pain-free
range is appropriate at this stage – they will stimulate
fibroblast activity and promote the production of colla-
gen tissue. This is an example of the plasticity described
earlier in the chapter.
Beyond the fourth day post-injury, proliferation of new,
strengthening the healing of the injured tissue. As a result
of this, increasingly greater ranges of pain-free movement
can be expected. The physiotherapist needs to encourage
their patients to practise these movements frequently
throughout the day. Taking the movements to their
pain-free limit will begin to progressively load the newly
developing tissues and will facilitate an inbuilt progres-
sion of activity because as the pain eases progressively
263
 Tidy’s physiotherapy
Clinical note
Caution is needed with some injuries in the proliferative
stage so that the movements produced do not promote
calcification within the associated soft tissues, for
example following quadriceps contusion, so called ‘dead
leg’ (haematoma of the thigh). In dead leg, the
quadriceps muscle is crushed against the femur by a
direct blow. This injury commonly causes damage to the
periosteum of the femur, which causes osteoblasts to
move into the overlying soft tissues (quadriceps). Overly
aggressive early movement can promote osteoblastic
activity within the muscle, which may develop into
myositis ossificans.
A large observed difference in uninjured–injured knee
range immediately post-injury and being unable to play
on following injury are both key early indicators of
myositis ossificans developing as a likely complication
(Alonson et al. 2000).
more range of movement will be achievable. This will
promote the further formation and alignment of collagen
and hence promote repair and the development of a func-
tional scar (Watson 2004). However, care must continue
to be taken, as during this phase any excessive loading still
has the potential to damage the newly-formed tissue
thereby provoking further injury and delaying the repair
process.
Range of movement exercises will contribute to the
maintenance of muscle strength and promote tissue-­
loading, but during this stage it is normal practice to limit
the amount of overt strengthening/timing/control exercise
recommended to the patient until full, non-weight-bear-
ing pain-free active and passive ranges of movement are
achieved. The use of isometric contractions involving
structures not directly affected by the injury can be com-
menced early in the process.
Clinical note
A patient with a severe second-degree sprain of the
lateral complex of the ankle can safely exercise the knee
and thigh area during the proliferative stage. The degree
to which the muscles of the thigh can be loaded may be
influenced by the ability of the patient to weight-bear.
Other available physiotherapeutic techniques suitable at
this stage include reciprocal inhibition. This can be useful
to increase range of movement and increase tissue length
(Waddington 1976). Reciprocal inhibition is the physio-
logical phenomena which occurs when a skeletal muscle
(antagonist) contracts and the opposing muscle (antago-
nist) relaxes. These techniques can be useful when trying
264
to encourage elongation of the musculotendinous appara-
tus. Their main use is when muscle tension or muscle
spasm is identified as the reason for limited range of
motion.
Very gentle passive static stretching of affected tissues
can begin at this stage as long as precautions are taken not
to be over zealous. Again, the patient’s pain report is the
main indicator of the amount of stretch that it is safe to
apply. Ballistic stretching would not be advocated at this
stage, as the potential to overstretch the newly forming
tissues and reinjure while performing this technique
is high.
Clinical note
A person with a grade 2 hamstring injury that occurred
six days ago is likely to be at the stage where some
encouragement of increasing length in the hamstrings
is desirable to load the newly forming collagen tissue
in order to promote further proliferation and repair. In
clinical practice this is often difficult owing to protective
muscle spasm in the affected hamstring group. Reciprocal
inhibition whereby active contraction/shortening of the
quadriceps group is used to induce relaxation and
lengthening in the hamstrings can be used. This can be
achieved by placing the individual on their unaffected
side, fixing the hip of the affected leg in 40 degrees of
flexion (thereby ensuring minimal stretch on the
hamstrings over the hip joint), moving the knee into
extension until slight stretch in the hamstrings is felt and
then providing isometric resistance to the quadriceps. As
this resistance is applied to the quadriceps, the opposing
muscle group (hamstrings) relaxes reciprocally and allows
further elongation. This provides a load to the newly
forming fibrous tissue and therefore facilitates repair. The
skill in this technique is in ensuring that the lengthening
achieved in the hamstrings is slow and controlled. In
addition, undue pain in the hamstring group should not
be provoked by this technique.
As the tissues continue to proliferate, more fibrous
tissue is laid down and the healing tissues begin to get
stronger. During this time corresponding increases in the
forces applied to the tissues can be made by increasing the
force of stretch applied, increasing the range of movement
produced and increasing the number of repetitions of any
activity.
As a progressively greater load is applied to newly
forming fibrous tissue it begins to remodel in response to
the increasing forces applied. In addition, it is proposed
that the haphazard arrangement of collagen laid down in
the early healing stages begins to take on a more organised
pattern as load is applied to it. The collagen fibres begin
to align themselves along the lines of the stress. It is impor-
tant, therefore, that the stresses applied to newly forming
 The physiotherapy management of inflammation, healing and repair
tissue are directed along the functional lines of stress
normally required by that tissue. This requires the physi-
otherapist to apply their anatomical knowledge in an
effective way.
From about the sixth day post-injury onwards there
are increasing amounts of fibrous tissue laid down and,
correspondingly, increasing levels of activity can be
promoted. Tissues should be stressed progressively. It is
considered to be both safe and advantageous to warm-up
the affected tissues prior to activity – this has the effect of
reducing the amount of load required to stress the tissues
(compared with cold tissue) and therefore the tissue can
be stressed more safely.
Electrotherapy in tissue healing   on the best available evidence. It must be remembered that
and repair
The use of electrotherapy in the healing and repair pro-
cesses has long been discussed and, again, there is varied
evidence to support or discount the use of modalities such
as ultrasound (US), pulsed electromagnetic energy and
laser therapy in facilitating these processes. Electrotherapy
as a topic is very large and this chapter does not claim to
fully address all the literature and physiology surrounding
it. The reader is referred to the electrotherapy chapter and
other texts and literature for further information and dis-
cussion of these topics.
The most common electrotherapy modalities that
appear to have the potential to have a direct action on the
tissue repair process are US, pulsed shortwave diathermy
(PSWD) and laser therapy. There is substantial evidence to
support the notion that these modalities all have the
capacity to influence the normal physiological processes
of tissue repair, particularly the early inflammatory stage;
however, clinical trials that demonstrate their efficacy in
the clinical situation are lacking.
Watson (2006) describes a simple model of electro-
therapy (Figure 12.3). This model summarises that the
machine-generated energy in one form or another is deliv-
ered to the tissue. This energy is then absorbed by the
tissue (to varying degrees depending on type), which then
results in a change in one or more physiological events. It
is the result of the energy being absorbed by the tissues
resulting in a physiological shift, which is referred to as
the therapeutic effect.
Theory
Treatment delivery
Dose calculation
Deliver Physiological
energy effect(s)
Figure 12.3  A simple model of electrotherapy. Reproduced
from Watson (2006) with permission.
Chapter 12
Choosing when and how to
use electrotherapy?
Like any modality such as manual therapy, exercise or drug
therapy there is an optimal time to apply it and appropri-
ate dosage or intensity.
Watson (2006) suggests that the clinical reasoning
process behind the use of electrotherapy can be illus-
trated by working through a reversal of the model shown
(Figure 12.3).
Starting with the patient and knowing their identified
physiotherapy problems and stage of healing and repair,
the clinician can now work out what physiological
effect is required and on what type of tissue. Once this is
known the appropriate modality can be chosen based
if there is no electrotherapy modality suitable to achieve
the desired result then electrotherapy has no place in the
management of this condition at this particular time
(Watson 2006).
Research suggests that it is the dosage applied and the
specific tissue type that appears to most greatly influence
this physiological shift. Studies have shown that different
modalities applied at different dosages can have very dif-
ferent physiological effects. There does not yet seem to be
an optimal dosage identified for any of these modalities
for specific tissue types, thus making it difficult for the
clinician to fully justify their choice in dosage.
In the proliferation stage it may be appropriate to con-
tinue to apply electrotherapeutic modalities, again ensur-
ing that this is only used when an appropriate therapeutic
window for the modality selected exists. During this phase
of tissue proliferation the processes of phagocytosis,
fibroblast and myofibroblast proliferation, and protein
synthesis are prevalent. These processes can be therapeuti-
cally enhanced by the use of US, laser or PSWD. All of
these modalities have the potential if selected appropri-
ately (i.e. related to their specific tissue absorption proper-
ties), applied at the appropriate time and at an appropriate
dose to exert a pro-proliferative effect whereby collagen
synthesis is enhanced. This enables a speeding up of the
proliferative phase and can therefore facilitate the rehabili-
tation process.
PHASE 4: TISSUE REMODELLING  
(10 DAYS + POST-INJURY)
Therapeutic Pathophysiology
effect(s)
Key processes involved in the phase of tissue remodel-
ling are:
Patient
• ongoing fibroblast activity and collagen production
(usually peaking 2–3 weeks following injury);
• absorption of older fibrous tissue;
265
 Tidy’s physiotherapy
• deposition of new fibrous tissue;
• scar tissue contraction;
• type III collagen fibres being replaced by type I
collagen fibres.
You must remember that the different phases of the
healing and repair process do not occur in perfect sequence.
The phase of tissue remodelling and soft tissue contraction
overlaps significantly with the earlier proliferation phase
(see Figure 12.2). Remember that the peak of fibrous tissue
repair occurs 2–3 weeks after the injury and the whole
healing process is a dynamic one as older fibrous tissue is
removed and new scar tissue is laid down. The continued
application of physical stress to the developing tissues is
one of the most significant factors influencing this phase
of the repair process. The newly laid down fibrous tissue
becomes ‘more organised’, being arranged less randomly
and beginning to orientate itself along the lines of stress,
thus enabling them to function more normally. This is the
beginning of the remodelling phase which can continue
for months and, possibly, for more than a year. It is clear,
therefore, that this process continues long after the notice-
able healing process and definitely beyond the time in
which the patient would be in direct contact with the
physiotherapist within the active rehabilitation process.
This means that it is important that therapy, usually in the
form of activity and exercise, continues long after an indi-
vidual has been discharged from the ongoing care of the
physiotherapist. Some evidence shows that even at this
stage remodelling is still ongoing and tissues have not
returned to their full functional capacity. Research in ante-
rior cruciate ligament repair in monkeys indicated that the
repaired anterior cruciate ligament reached 56%, 76% and
96% of its normal tensile strength 6 weeks, 12 weeks and
24 weeks after repair respectively. While this extent of
remodelling may be acceptable in some members of the
population it may not be so in others.
A key feature of the remodelling phase is soft tissue
contraction. This is a process by which the newly formed
tissues begin to physically shorten. This process has the
potential for the healing tissues to begin to restrict and
limit mobility and range of movement in the affected
tissue. This process of soft tissue contraction begins to
occur around the third week post-injury and continues
long into the remodelling phase. As this process continues
long after a patient would normally be discharged by the
therapist, it is a key influence on the nature of the ongoing
Clinical note
The potential for tissue reinjury during the process of soft
tissue contraction is clear. Failure to address this and plan
activity and exercises strategies to avoid it is a potential
key influence on reinjury patterns.
266
prescription of activity and exercise given to patients fol-
lowing discharge.
This phase of remodelling process takes place following
the proliferative phase and is referred to as the chronic
stage in some texts. Within this chapter, this phase is
seen as a natural progression following the proliferative
stage in an uncomplicated process of proliferation and
remodelling.
General physiotherapy aims in the
remodelling stage (phase 4)
The aims of physiotherapy in the remodelling stage may
include any, or all, of the following:
• promoting collagen growth and fibre/tissue
realignment;
• increasing the range of movement:
 active;
 passive;
 accessory;
• increasing muscle strength/control/timing;
• preventing soft tissue adaptation in injured and
non-injured tissues;
• maximising function.
Physiotherapy in the remodelling
phase (Phase 4)
These aims can be related to the ongoing pathophysiologi-
cal processes involved. Fibroblastic activity increases and
new collagen fibres continue to be laid down. This process
peaks around 2–3 weeks post-injury, continues through to
4–6 weeks following injury and is clearly extended beyond
this timeframe in more severe injuries. Ongoing attention
to progressive activities started in days 3–10 post-injury is
required. The purpose of the physiotherapeutic treatment
is to promote movement and mobility of the injured
structures/tissues.
Preventing tissue contraction and
adhesion formation
Beginning around the third week post-injury the healing
scar tissue begins to undergo a process known as soft tissue
contraction. This means that the physical length of the
tissue actually begins to get shorter. Consider this in the
case of a hamstring injury as described above. At the same
time that you are working with the patient therapeutically
to lengthen the hamstrings the remodelling tissue begins
to cause the healing scar tissues to shorten. This is a
process that can go on for a considerable period of time
after the injury. At this stage, it is normal for the patient
to experience some discomfort during end-range stretch-
ing activity.
 The physiotherapy management of inflammation, healing and repair
Clinical note
In practice this means that end of range stretching
should commence on the third week following injury and
should continue until the scar tissue contracture process
is completed. The reality of this is that this is a very
long-term process which may need to continue for as
long as the remodelling process goes on. As indicated
earlier this may be in excess of a year.
Contractures can sometimes become permanent. In
these cases it becomes impossible to stretch the scar tissue.
This is known as fixed contracture. Fixed contractures
develop when the normal connective tissues (which are
elastic) are replaced by fibrous tissue (which is inelastic).
This means that the tissue will not stretch and this pre-
vents normal movement. Contractures can occur in any
tissue. The key to preventing the development of fixed
contractures lies in ongoing therapeutic exercise and activ-
ity aimed at ensuring that as the scar tissue forms it
remains a mobile, functionally-able structure. At the end
of the remodelling stage the injured soft tissue will be
repaired by scar tissue. The desired outcome is that this
final scar is able to be a functional replacement for the
tissues initially injured.
A potential problem during the remodelling phase is the
formation of soft tissue adhesions. This is where newly
forming fibrous tissue has been produced between adja-
cent layers of tissue such that these layers become bound
together. These adhesions, when formed, can severely
limit movement and soft tissue function. Normal move-
ment requires that adjac­ent layers of tissue are able to
move independently, for example a tendon moves over a
bony surface or beneath a fascial band such as retinacula
while the bone/retinacula stays still. As the formation of
fibrous tissue during the proliferation phase is completely
random, the potential for the development of adhesions
Clinical note
It is worth considering what happens in the soft issue
repair processes following fracture, for example a patient
sustaining a fracture of the distal radius is normally
immobilised within 6–8 hours of the fracture in a plaster
cast, which remains in place for a minimum of four
weeks. During this time the normal soft tissue repair
phases of bleeding, inflammation, proliferation and some
remodelling all occur while the arm is immobilised.
During this time, the tissues are not subject to any of the
beneficial loading described in this chapter. When the
plaster is removed, improving mobility and range of
movement in the tissues can take significant periods
of time.
Chapter 12
is real. Movement in the early stages of healing and
repair helps to ensure that the newly forming tissues do
not create these adhesions. In some healing processes,
where long periods of immobility are part of the patient
management, their formation is probably inevitable.
Soft tissue adhesions are normally easily palpable – tissues
feel thickened and immobile to soft tissue palpation and
mobilisation.
Passive and accessory mobilisation
techniques
Other techniques aimed at restoring full working/
functional length in tissues include passive and accessory
movement techniques. The application of these demands
the use of an in-depth knowledge of human anatomy.
This means that the physiotherapist can select the ap­­
propriate techniques to attempt to influence a specific
structure.
Activity and exercise continue to play a key part in the
physiotherapy management. A shift towards an activity
and exercise programme placing more emphasis on
improving muscle strength/timing/control is normally
seen at this stage. It is important to consider all the
ways in which the tissues in question are loaded during
normal functional activity. This enables the physiother-
apy programme to be tailored appropriately to an indi-
vidual’s need.
Muscle tissue will need to be able to withstand load
from active and passive forces, from concentric, eccentric
and isometric contractions at varying points within its
range. It may need to work in an open-chain or closed-
chain environment; it may need to function as an agonist,
antagonist, synergist or fixator; it may need to generate
strength, power or endurance. All of these factors must be
considered when developing patient-specific exercise and
activity programmes in the remodelling phase. Only when
all of these things are considered and incorporated effec-
tively into an exercise and activity programme is the
potential for rehabilitation of individuals back to their full
and maximum functional capacity realised.
Clinical note
Returning a patient to full road-running function
following a second degree sprain of the hamstring
muscles requires full range of motion in the joints of the
lumbar spine, hip and knee, appropriate muscle control
of the leg musculature (a combination of concentric,
eccentric and isometric contractions), the ability to run at
different speeds on different surfaces (including inclines)
and to varying distances. All of these aspects must be
covered in the final rehabilitation programme if the
individual is to reach their maximum potential.
267
 Tidy’s physiotherapy
The context of an individual’s normal functional activity
is paramount to effective physiotherapy practice, whether
it be playing a 90-minute game of football in the premier-
ship or getting into and out of a car. The key skill that the
physiotherapist utilises here is that of movement analysis.
By analysing the demands of the activities that an indi-
vidual aspires to be involved in, the physiotherapist is able
to plan rehabilitation to meet individuals’ needs with the
aim of maximising each individual’s capacity. Too often,
in the author’s opinion, the lowest common denominator
of functional ability is accepted. This becomes the norm
and physiotherapeutic intervention fails to enable indi-
viduals to achieve their full potential.
Tissue remodelling is a prolonged process which is espe-
cially pertinent in young patients who are remodelling
and growing at the same time. In this client group, remod-
elling periods are often prolonged beyond the normal
periods for adult members of the population.
Clinical note
Returning a patient to playing rugby following a
dislocated shoulder requires an analysis not only of the
demands of rugby per se but also an analysis of the
specific position that a player may take on the field. They
need to be able to throw and catch while running, to be
able to run with the ball, and to tackle and be tackled.
In addition, they will need to be able to withstand a
direct fall onto the affected arm.
268
Clinical note
A window cleaner returning to work after a second
degree sprain of the lateral ligament complex of the
ankle requires full range of motion in the joints of the
ankle complex and foot, appropriate muscle control of
lower leg musculature (a combination of concentric,
eccentric and isometric contractions), and the ability to
walk at different speeds on different surfaces and to
varying distances. He must also be able to balance on a
limited base of support, at a variety of heights, for
significant time periods while cleaning windows. Finally,
he will probably need to be able to land steadily on his
foot when jumping from a height. All of these aspects
must be covered in the final rehabilitation programme if
the individual is to reach their maximum potential.
Clinical note
It should be acknowledged that while this chapter
identifies the key influences that physiotherapy could
have on the process of tissue healing and repair, in cases
of severe and extensive soft tissue trauma a degree of
permanent loss of function of the tissues affected is
inevitable. This loss of function within the tissues may
lead to a degree of long-term disability for the individual
affected.
 The physiotherapy management of inflammation, healing and repair Chapter 12

CASE STUDY
AN INJURED HAMSTRING
Joe is a 25-year-old university student who plays football on a weekly basis. He injured his right hamstring while playing
football yesterday. He describes a sudden onset of pain in the posterior thigh while he was running. He was unable to
play on and hobbled off the pitch. There was no first-aid advice available. He spoke to a friend who recommended he
went to see a local physiotherapist. Joe has self-prescribed ibuprofen and paracetamol. He is otherwise well and has had
no previous injuries.
Joe attends the physiotherapy clinic the next day and limps into the clinic, weight-bearing only through his toes on the
affected leg.

Table 12.1  Case study: An injured hamstring

Treatment aim Treatment intervention

To protect newly damaged tissue from further damage
To reduce metabolic demands of tissue
To prevent and reduce swelling
Cryotherapy: apply ice pack or ice compression device to
injury site (20 mins minimum duration regularly through
day)
Compression application of elasticated strapping (as
described above)
Elevate affected limb for intermittent periods. Beware of
combination with prolonged extensive compression

To reduce pain Use of crutches initially to protect injured area, encourage

To protect newly forming tissue from disruption
To prevent soft tissue adaptation in non-injured tissues
To promote collagen growth and fibre realignment
To increase and restore normal joint range of movement
(passive, active and accessory)
weight-bearing as pain allows
Pain at the early stage should be seen as a protective
mechanism to protect and prevent further damage;
encourage movements of hip and knee within pain limits
Anything that provokes pain at anything other than a
minimal level should be discouraged initially
Increase passive and active movements of the hip and
knee, and then combine movement of both joints to
increase stretch and load on tissues

To maintain and increase muscle strength, timing and
control
To increase proprioception of affected lower limb
To increase tensile strength of new collagen tissue
To restore and encourage optimal function in relation to
patient’s needs
Progress active and dynamic activity looking at lower limb
and pelvis as a whole. Increase activity/football-specific
tasks to improve proprioception, timing and
neuromuscular control

269
 Tidy’s physiotherapy

CASE STUDY
AN INJURED ANKLE
Margaret is a 55-year-old hotel receptionist who slipped while coming down the stairs this morning sustaining an inversion
injury to her left ankle. She is unable to weight-bear and has severe pain in her foot and ankle, and therefore attended
the accident and emergency (A&E) department at her local hospital. X-ray revealed no bony injury. She is provided with
crutches and taught to non-weight-bear. She is given an appointment to see the physiotherapist in A&E that afternoon.

Table 12.2  Case study: An injured ankle

Treatment aim Treatment intervention

To protect newly damaged tissue from further damage
To reduce metabolic demands of tissue
To prevent and reduce swelling
Cryotherapy: apply ice pack or ice compression device to
ankle/foot (of about 15 min minimum duration regularly
through day). Monitor for reactions. Remember tissues
are superficial and minimal subcutaneous fat
Compression: application of elasticated strapping,
particularly when patient is mobilising and not elevating
distal limb (as described above)
Elevate affected limb for intermittent periods. Beware of
combination with prolonged extensive compression
Advise regarding minimising walking and standing in first 5
days to minimise accumulation of swelling

To reduce pain Teach safe use of crutches initially to protect injured ankle
To protect newly forming tissue from disruption with weight-bearing as pain allows
To prevent soft tissue adaptation in non-injured tissues Pain at the early stage should be seen as a protective
To promote collagen growth and fibre realignment mechanism to protect and prevent further damage
To increase and restore normal joint range of movement Encourage movements of knee, ankle and foot within pain
(passive, active and accessory) limits
Anything that provokes pain at anything other than a
minimal level should be discouraged initially
Encourage normal gait pattern without use of crutches as
pain and acute stage ends
Increase passive, and active movements of the knee, ankle
and foot, and then increase stretch and load on tissues
Consider using accessory joint mobilisations to maintain/
increase range of movement at the distal tibiofibular,
talocrural, subtalar and mid-tarsal joints

To maintain and increase muscle strength, timing and
control
To increase proprioception
To increase tensile strength of new collagen tissue
To restore and encourage optimal function in relation to
patient’s needs
Progress active and dynamic activity looking at lower limb
and pelvis as whole. Increase activity/specific tasks to
increase proprioception, timing and neuromuscular
control of lower limb, particularly around the foot and
ankle
Consider occupation and return to work. Can job be
adapted initially to allow early return to work or is time
off appropriate. Consider all patient’s needs in terms of
sport and activities

270
 The physiotherapy management of inflammation, healing and repair
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271
 Chapter
Exercise in rehabilitation
Duncan Mason
INTRODUCTION
Exercise is one of the cornerstones of rehabilitation,
widely used by many types of health professionals to
manage an even wider range of medical conditions. It
could be defined as ‘using voluntary muscle activity pro-
duced by the integration of higher centres, cardiovascular,
pulmonary and neuro-musculoskeletal components to
rehabilitate these systems.’ The aims and reported effects
of exercise are also numerous. Throughout this chapter
we will see an evidence-based overview and rationale
behind some of the more commonly encountered types
of exercise.
Exercise is frequently used to enhance the recovery
rate of all components of the movement control system,
namely the musculoskeletal and central nervous system
(CNS), to increase the range of motion, increase muscle
strength, develop a higher level of proprioceptive feed-
back and develop an overall improvement in sensori-
motor control. However, the list of benefits does not end
here; exercise is used in rehabilitation of the cardiovas-
cular and pulmonary systems (Rees et  al. 2004), which
are required to provide the raw fuels for the physiological
processes involved in muscle contraction. Also, exercise
has been shown to have beneficial effects on the higher
centres, reducing the effects of some mental illnesses
(Galper et  al. 2006). This explains its invaluable use in
this area of healthcare.
Exercise can be delivered in a variety of ways: in the
clinical setting or by teaching home exercises; as an indi-
vidual or in a group setting; on land or in water. All
approaches need to be considered to select the most
appropriate for the individual requirements of each
patient. The way in which the exercise is taught or
13 
delivered to an individual is also important in the ultimate
success of this modality. This, too, will be discussed in the
course of this chapter.
To summarise, exercise is a widely used treatment
modality, which has been shown to be effective in the
management of many medical conditions when appropri-
ately selected and applied.
Glossary of terms
Delayed-onset muscle soreness (DOMS) A dull, or
frequently more severe, aching sensation that follows
unaccustomed muscular exertion. It is often associated
with athletic activity. Eccentric exercise activity is said to
provoke symptoms more readily owing to microtrauma
– minor damage as a result of strenuous exercise.
Soreness usually peaks 24–48 hours after exercise
(Cheung et al. 2003)
Kinetic chain exercise Closed kinetic chain is an exercise
performed where the distal segment of the limb is fixed
(e.g. knee squats with feet on the floor). Open kinetic chain
is an exercise where the distal segment of the limb is able to
move freely in space (e.g. a biceps curl with a free weight)
Muscle contracture The adaptive shortening of muscle or
other soft tissues that cross a joint, which results in
limitation of range of motion (Kisner and Colby 1996)
Muscle spasm A persistent muscle contraction that
cannot be voluntarily released
Muscle spasticity A condition associated with
hyperactivity of the stretch reflexes and tendon
stretch receptors, due to loss of inhibitory influences
on the alpha-motor neurones on the motor unit
(Mense et al. 2001)
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 Tidy’s physiotherapy
Muscle stiffness (also sometimes referred to as muscle
tension) An increase in background resistance to passive
movement of soft tissues over a joint. This is often
necessary to enhance function and is not necessarily an
undesirable occurrence
Muscle tone The resting activity level or tension of a
muscle, clinically determined as resistance to passive
movement or to deformation
Myalgia Pain felt within a muscle
Proprioception The specialised variation of the sensory
modality of touch that encompasses the sensation of
joint movement (kinaesthesia) and joint position (joint
position sense) (Lephart et al. 1997)
Stretching Any therapeutic manoeuvre designed to
lengthen pathologically shortened soft-tissue structures
and thereby increase range of motion (Kisner and Colby
1996).
STRENGTHENING EXERCISES
Introduction
Strengthening exercises are aimed at increasing the torque-
producing capacity or endurance of a specific muscle or
muscle group.
Adequate muscle strength is necessary to perform many
activities of daily living whether it is to achieve self-care,
occupational tasks or elite athletic performance. As a result
of many pathologies muscle strength can be lost, whether
directly caused by a trauma resulting in a disruption in the
motor control mechanism or indirectly, for example as a
result of pain inhibition or disuse atrophy. Pathological
disruption to the nerve supply will also directly affect
motor unit recruitment and therefore strength.
An evaluation of muscle strength is usually performed
as part of a patient’s objective examination. This should
assist the therapist’s clinical reasoning and enable them to
rationalise an appropriate point to start strengthening
rehabilitation from.
As a strengthening exercise programme is undertaken
physiological changes occur within the muscle to increase
its capacity to produce torque and sustain muscle contrac-
tions. This allows exercises to be progressed, in turn, to
further overload and strengthen the muscle. Overload is
an important component in an effective strengthening
programme.
Therapists commonly employ several types of strength-
ening exercise
• free active;
• isometric, concentric, eccentric;
• open/closed kinetic chain;
• resisted.
274
These will be discussed in further detail in the remain-
der of this section and will be used depending on the
strength requirements of the individual.
Other factors such as the number of repetitions, how
often they are performed, i.e. number of sets, frequency
per day and the load applied are also important factors
dependent on the intended outcomes.
Measurement of muscle strength
Key point
It is important for a physiotherapist to measure muscle
strength objectively when assessing an individual, to
obtain a baseline level from which future improvements
(or lack of them) can be gauged. This allows the
therapist to devise an individual exercise plan and to
evaluate the effectiveness of a prescribed exercise
regimen.
Muscle strength can be evaluated in a number of ways:
manually, functionally or mechanically.
The Oxford scale
The Oxford scale has been devised to manually assess
muscle strength and is widely used by physiotherapists.
According to the Oxford scale, muscle strength is graded
0 to 5. Table 13.1 summarises the grades.
There are limitations to the usefulness of the Oxford
scale. These include:
• a lack of functional relevance;
• non-linearity (the difference between grades 3 and 4
is not necessarily the same as the difference between
grades 4 and 5);
Table 13.1  The Oxford scale
Grade Muscle contraction
0 No contraction
1 Flicker of a contraction
2 Full-range active movement with gravity
eliminated (counterbalanced)
3 Full-range active movement against gravity
4 Full-range active movement against
light resistance
5 Normal function/full-range against
strong resistance

• a patient’s variability with time (alternating between
grades owing to fatigue, for instance);
• a degree of subjectivity between assessors;
• assessment of muscles acting only concentrically;
• the difficulty of applying the scale to all cases in
clinical practice (so that strength is rarely evaluated
throughout full range as many individuals seen by
physiotherapists do not possess full range in the first
place).
Owing to these shortcomings, modified versions of the
Oxford scale are commonly seen in clinical practice.
Functional tools
Functional tools or scales can be used to evaluate strength
and can be related to a specific activity or to one of its
components. These tools are commonly employed when
rehabilitating sportsmen back to competition, for example
the triple hop test, designed to identify functional, unilat-
eral lower limb differences. Sport-specific activities can be
monitored by a physiotherapist with a working knowledge
of the demands of a particular sport, its training and com-
petitive requirements.
Isokinetic assessment
Isokinetic assessment has been used with increasing fre-
quency since its inception in the 1970s. It involves the use
of computerised evaluation of movement when exercising
at a preset angular velocity on the isokinetic equipment
(Figure 13.1).
This means that the subject can push as hard or as little
as desired and the machine will move only at the preset
velocity. It is therefore the resistance provided by the
machine that varies.
The use of isokinetics has functional relevance as it can
evaluate both eccentric and concentric activity through
range.
Figure 13.1  A typical isokinetic machine.
Exercise in rehabilitation Chapter 13
Key point
Isokinetic machines are used for treatment, as well as
assessment. They produce objective, reproducible and
quantifiable data, and therefore have obvious advantages
over other methods used in evaluating strength in the
progression and monitoring of rehabilitation of strength
deficits.
Drawbacks
The drawbacks of isokinetics relate to its function, as
natural human movements rarely occur at fixed velocities.
Also, the machine operates on a fixed axis of movement,
which does not replicate the instantaneous axis of move-
ment found in most normal joints. The equipment can
also be time-consuming to set up and not all practitioners
will have access to it.
Additional limitations have been acknowledged by
Lieber (1992). These include the time required to recruit
muscle fibres (50–200 ms), making this period of data
obtained unusable. Another drawback is the limb striking
the testing bar at the end of the movement, although
some isokinetic units employ a damping mechanism to
prevent this.
Key point
While isokinetics can give the practitioner a good idea of
any underlying deficiencies in the musculoskeletal
system, there is no single tool to evaluate strength that is
both totally functional and quantifiable.
Strength training
Benefits
Strength training can include free active exercise or resist-
ance training, when the body must overcome this resist-
ance to produce the movement. This may be simply by use
of body weight or free weights, or by the use of other
equipment such as exercise machines in a gymnasium.
Resistance training can also be used to train submaximal
and endurance work. All aspects of resistance training can
be incorporated into various rehabilitation programmes.
Some of the reported physiological benefits of resistance
training are:
• increased cross-sectional area of muscle;
• increased muscle fibre size;
• increased or maintained bone density;
• increased tensile strength of tendons and ligaments;
• decreased heart rate.
275
 Tidy’s physiotherapy
In order for a muscle or muscle group to develop suf-
ficient strength gains it must be loaded progressively, oth-
erwise strength improvements will be limited. This factor
can often be overlooked when rehabilitating an individual
and failure to progress exercise may result in a lack of
improvement on the part of the patient.
Initial improvement in strength, when measured objec-
tively, may be rapid without noticeable changes in physical
characteristics. This is a result of enhanced neuromuscular
coordination and utilisation of previously redundant
motor units. More motor units are recruited within a given
muscle and a stronger contraction of the muscle is there-
fore produced. This neural adaptation occurs before other
physical and physiological changes that result from resist-
ance training. It can be said, therefore, that there are
two mechanisms that we aim to employ when applying
strengthening exercises: firstly, the physiological adapta-
tions occurring in the muscles, which take 6–8 weeks; and,
secondly, the neural adaptations to facilitate more motor
units within a muscle, which happens a lot sooner.
Further study
To gain deeper knowledge on the physiological processes
involved in producing muscle contraction and the
adaptations that occur, it is necessary to study your
recommended physiology text. Study the sliding filament
theory and formation of actin and myosin cross bridges.
Free active exercise
These strengthening exercises are performed when the
only external resistance that is to be overcome is the resist-
ance provided by the weight of the body part. These exer-
cises are used when the individual is at grade two or three,
or below, on the Oxford scale for the targeted muscle
group. Certain strategies are employed when dealing with
an individual with this level of disability. Exercising the
muscle in its middle range is the most effective part of the
range for facilitating muscle activity, followed by inner
range and then outer range. In middle range there is
optimum length for formation of actin and myosin cross
bridges; in outer range there is less capacity than inner
range, although having more overlap does not allow
optimal cross bridge formation. The use of overflow can
also facilitate muscle activity, for instance when applying
a force at another muscle in the region which normally
works functionally with the targeted muscle or by working
the corresponding muscle on the other side of the body.
Muscle contractions can also be enhanced by use of
afferent input to the CNS, touching the corresponding
dermatome (area of skin sharing the same nerve root
innervation). Vocal encouragement, visual feedback and
276
Table 13.2  Types of muscle contraction
Type of Characteristics
contraction
Isometric Muscle maintains same length
throughout the contraction
Concentric Muscle contracts from a relatively
lengthened position to a shorter
position
Performed either against gravity or
against load/resistance
Outer range to inner range
Eccentric Muscle contracts from a relatively
shortened position to a longer position
Performed either with gravity or a
controlled release of a load/resistance
Inner range to outer range
the use of biofeedback units, such as electromyography,
are all useful in facilitating activity in redundant motor
units. The type of muscle contraction used can also have
a bearing on the effectiveness of the exercise.
Muscle contractions
Muscles can contract in three different ways: concentri-
cally, eccentrically and isometrically. The characteristics of
these different types of contractions are summarised in
Table 13.2.
Key point
Sometimes the terminology isotonic shortening and
isotonic lengthening may be seen instead of concentric
and eccentric contraction. These terms are best avoided
as they imply one contraction is an opposite of the other,
whereas, physiologically, their characteristics vary greatly.
Individual muscles often exhibit more than one type of
contraction at a time. Consider the muscle work occurring
in the hamstring muscles in Figure 13.2.
The proximal part of the muscle is lengthening (control-
ling hip flexion) and the distal part is shortening, control-
ling tibial movement.
The features of eccentric exercise when compared with
concentric exercise are, on the positive side, that it is
mechanically more efficient and metabolically more effi-
cient, but, on the negative side, it is less resistant to fatigue
and may result in DOMS micro-trauma inflammation
between sarcomeres. See Table 13.3 for further examples
of eccentric activity.

Figure 13.2  Concurrent dual contraction during a squat.
Table 13.3  The functions of eccentric muscle work
Function Example
Deceleration of a Kicking a football: the hamstrings
limb part act to decelerate hip flexion and
knee extension
Force absorption Landing from a jump: the
quadriceps contract absorbing
some of the ground reaction
force thus reducing the joint
reaction forces
Controlling a Sitting down in a chair: gluteus
movement against maximus and the upper part of
gravity the hamstrings are controlling hip
flexion
DOMS is a dull aching sensation that follows unaccus-
tomed muscular exertion. It is a key characteristic occur-
ring following eccentric muscle activity. DOMS should be
differentiated from other types of muscle soreness that
occur during, or soon after, exercise owing to metabolic
factors, such as the build up of lactate.
DOMS is typically felt most acutely 48 hours after eccen-
tric exercise has been completed (Howell et al. 1993;
Rodenberg et al. 1993; Leger and Milner 2001). This com-
monly occurs in certain muscles of individuals under­
taking a particular activity infrequently that has quite a
high eccentric component. Examples include fell running
(quadriceps in the downhill component) or playing
squash (gluteus maximus when reaching for a low shot).
DOMS is effectively the occurrence of local micro-
trauma within the muscle. A key site for this inflammation
is between adjacent sarcomeres or within the Z bands.
Evidence for this inflammatory reaction can be found
in increased levels of creatine kinase (CK) in the blood
Exercise in rehabilitation Chapter 13
following exercise. This enzyme is released into the blood-
stream following a muscular injury. Occasionally, the high
CK levels found following eccentric exercise can confuse
the clinical picture of a patient in whom CK levels may be
used as a means of informing clinical diagnosis (Gralton
et al. 1998). Saxton et al. (1995) have also reported a
decrease in proprioceptive function with high-level eccen-
tric exercise.
Despite many suggestions of dietary, medicinal, massage
and exercise remedies there is conflicting evidence as
to how best to enhance recovery from DOMS (Bennett
et al. 2005; Close et al. 2005; Racette et al. 2005; Rahnama
et al. 2005).
Treatment with eccentric exercise
Eccentric exercise has been identified as a key treatment
technique when rehabilitating tendon injuries, such as in
the tendo-achilles. Stanish et al. (1985) proposed treat-
ment protocols with eccentric exercise involving alteration
in both load and speed.
Key point
It is important to acknowledge that tendons function by
storing elastic energy via elastic deformation and recoil. It
may be that improved conditioning from isometric and
eccentric exercise to the muscles (e.g. gastrocnemius and
soleus) to which they are attached may also be a factor
in studies reporting the positive benefits of eccentric
exercises in tendon rehabilitation.
The benefits of using eccentric exercise programmes for
tendon injuries are thought to include:
• enhancing muscle strength to improve movement
efficiency in the musculo-tendinous complex;
• increasing the tensile strength of the tendon;
• stressing healing tissue in a functional manner to
influence collagen deposition;
• influencing the organisation of collagen in a
structure.
Knowledge of the types of contraction whether eccen-
tric, concentric or isometric, is required when planning
strengthening exercises. Eccentric contractions are capable
of producing more torque than isometric, which, in turn,
are stronger than concentric contractions. Isometric exer-
cises are particularly useful when an area is immobilised,
for instance when a joint is immobilised in Plaster of Paris,
provided the contraction does not further damage soft
tissues or destabilise fracture sites as active movement
would be more likely to. It is useful to apply eccentric and
concentric exercises in a functional context during reha-
bilitation. The functions of eccentric exercise being the
277
 Tidy’s physiotherapy
Figure 13.3  Eccentric training of the hamstrings.
deceleration of limb part, for example hamstrings braking
knee extension when kicking a football, the absorption of
force, for example when landing from a jump, or control-
ling a movement with the recoil of resistance or with
gravity, for example during sit to stand (Figure 13.3).
Open-chain and closed-chain
kinetic strengthening
The emphasis on closed kinetic chain exercises has devel-
oped since the onset of accelerated protocols for anterior
cruciate ligament (ACL) rehabilitation and rehabilitation
of anterior knee pain pathologies. A closed kinetic chain
exercise occurs when the distal part of the limb (upper or
lower) is fixed on a firm surface. Squatting is a commonly
quoted example of a closed chain kinetic exercise, but
performing a leg press exercise with the feet in contact with
a metal footplate is also an example. Contemporary post-
operative management of ACL reconstruction currently
involves a combination of open and closed kinetic chain
exercise; this reflects the mixture of open and closed
kinetic functions in the knee and the lower limb as a
whole in everyday functional activities.
The following are some of the proposed benefits of
closed chain exercises in the lower limb:
• the shear force acting at the knee joint is reduced
compared with the last 30 degrees of open chain
extension (Wilk et al. 1996);
• they encourage more functional movement patterns;
• they stimulate co-contraction of the hamstrings,
helping to reduce anterior tibial translation
(important in ACL rehabilitation);
• they increase shoulder stability in the upper limb by
stimulating co-contraction of surrounding muscles of
the glenohumeral joint and scapula-thoracic
articulation.
Closed kinetic chain exercises are not just a valuable
part of lower limb rehabilitation, they are also widely used
278
to good effect in the upper limb, particularly when address-
ing scapular or glenohumeral stability problems.
Resisted exercise
Resisted exercise is a more progressive form of strengthen-
ing exercise used in the more advanced stages of rehabilita-
tion to achieve grade 5 on the Oxford scale. It is also an
essential component of the training regimes of athletes
aimed at enhancing performance and preventing the onset
of injuries. As the name suggests, it is an activity during
which an external resistance must be overcome to com-
plete the exercise. This external resistance could be
provided by the therapist during treatment, but, more
commonly, is provided by equipment. The conventional
means for this is by application of weight training with
the use of free weights or weight training equipment as
found in gymnasia. However, other equipment, such as
medicine balls, elastic tubing or wrist and ankle weights,
can be equally effective if used selectively. As larger weights
are applied in this type of training it is essential to ensure
that the patient has been progressively advanced to this
stage of rehabilitation and must be closely supervised
during the exercise, particularly whenever the loads are
progressed. This type of training can be used to promote
power or endurance in muscles and will be discussed in
more detail in the following sections.
Types of muscle fibre
There are three main types of muscle fibre, usually called
I, IIa and IIb, but newer subdivisions are now being
described, such as Ic, IIc and IIab (Scott et al. 2001). Indi-
vidual muscles are composed from all types, but have
different proportions of each. Some of the differences in
the physiological make-up of these muscle fibres are illus-
trated in Table 13.4.
The exact proportion of different fibre types is not con-
sistent between muscles or between individuals. These
characteristics are generally thought to be partly geneti-
cally determined and are part of the reason for the natural
selection that sees individuals excel in different sports or
play in different positions within a team. They are also
influenced by training applied to the muscle (Scott et al.
2001). However, some general points can be made.
• Postural muscles such as the soleus are involved in
maintaining position rather than dynamic activity
and therefore have a higher number of type I fibres.
• Muscles that may be involved in more dynamic
activity, such as the gastrocnemius, will have
proportionately greater numbers of fast twitch fibres
– types IIa and IIb.
• With age, the number and size of type II fibres
decreases (Rogers and Evans 1993), making tasks
that require a quick burst of strength more difficult.
This should be an important consideration when
rehabilitating elderly patients.

Table 13.4  Some characteristics of the muscle fibre types
Type I
Fitness component Cardiorespiratory fitness
Energy system utilised Aerobic
Contraction speed Slow
Numbers of mitochondria Many
Resistance to fatigue High
• There is evidence that muscle fibres can convert from
one fibre type to another. This occurs between types
IIa and IIb (Scott et al. 2001) in particular and is
known as plasticity.
Number of repetitions
The number of repetitions performed of a particular exer-
cise, along with load applied determines the type of
muscle training effect. Resistance training includes pure
strength work, as well as endurance work and, as a conse-
quence, the number of repetitions will be based on the
required outcome.
There is little clear evidence on the number of repeti-
tions that should be used, but there are many protocols
that can be used or adapted. A group of repetitions is
known as a set, with three or four sets of an exercise usually
being performed. This allows physiological recovery of the
muscle to occur and delays the effects of fatigue.
Instructing a patient to perform ten repetitions may be
the most appropriate number to prescribe for the particu-
lar weight and exercise, but there needs to be a method of
determining the weight required for these repetitions. It is
important not to lose sight of the purpose of resistance
training (particularly strength training) – one of progres-
sive overload to increase muscle strength and improve
function. Progressive overload will not occur with repeti-
tions of a weight that is too light and, as a consequence,
recovery will be slower.
The majority of protocols that are in existence for
strength training are based upon what are known as the
‘one repetition maximum’ (1RM) and the ‘ten repetition
maximum’ (10RM). The 1RM is the weight that can be
lifted once and only once in an exercise, with further
completed effort being prevented by fatigue (Cahill et al.
1997). Determining the 1RM therefore prevents a chal-
lenge in the clinical environment and perhaps explains
the sometimes arbitrary nature of repetitions given. The 10
RM is calculated similarly, i.e. the weight that can be
lifted ten times. Once the 1RM or 10RM are established,
weight training protocols can be calculated using percent-
ages of this figure.
Exercise in rehabilitation Chapter 13
Type IIa Type IIb
Muscular endurance Strength/power
Anaerobic Anaerobic
Fast Fast
Moderate Low
Moderate Low
Key point
Sets consisting of ten repetitions are commonplace
within exercise prescription. However, this is often just an
arbitrary number. Avoid giving ‘sets of ten’ without any
underlying rationale. It is often better when prescribing
and teaching an exercise to observe for signs of fatigue
and substitution to give a number of repetitions in a set.
It may happen to be ten, but more often than not this
will not be the case.
The number of repetitions prescribed is determined by
the objective of the exercise. If the aim is to increase power
then relatively few repetitions will be required, with long
rests between sets, to achieve gains provided a high load
is applied. Muscles with a higher proportion of type IIa
and IIb muscle fibres with a mobiliser function will
respond to this type of regime. If the aim is to increase
endurance then lower loads will be required, but longer
holds and higher frequencies of repetitions will be neces-
sary for suitable gains. These exercises will be suitable for
muscles with stability or postural function and a relatively
higher proportion of type I fibres.
Further study
For more detail on exact protocols consult a strength and
conditioning text.
Resistance training in different populations
The elderly
Physical strength decreases with age. Some of the reported
reasons for this decline are the following:
• a decrease in the number of actual muscle fibres;
• muscle fibre atrophy;
• impaired excitation–contraction coupling;
• an inability or decreased ability to recruit type II
motor units (Rogers and Evans 1993).
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 Tidy’s physiotherapy
It is important to appreciate these long-term declines
when addressing rehabilitation programmes with this
section of the population. The issues outlined above
related to progressive overload are just as significant but
can be forgotten. An increase in basic strength may mean
improved performance in functional tasks.
Children and adolescents
There is currently no evidence to suggest that resistance
training in children is harmful, provided it is well
supervised. The vast majority of adverse incidents have
been related to poor technique and/or unsupervised
activity. There have been no reports of growth plate
fractures in studies related to youth strength training
programmes.
The American Academy of Pediatrics has produced a
series of recommendations in this area that stress supervi-
sion and numbers of repetitions between the age of 8
and 15 years. Practising technique with no load is also
highlighted.
From a clinical viewpoint it is important to consider
appropriate resistance training programmes when reha-
bilitating children and adolescents, adhering to the same
principles of progressive overload.
MOBILISING EXERCISES
Introduction
These are exercises aimed at moving a targeted anatomical
structure a precise amount in order to gain a treatment
effect.
Soft tissue extensibility is a prerequisite for normal
functioning. Unfortunately, following injury, inflamma-
tion, prolonged abnormal postures and other factors,
such as exercise history, age and gender, this extensibility
can be lost.
Therapists regularly encounter people who have well-
established limitation of movement and need to be able
to recognise this presentation and act accordingly to
restore the length of the soft tissues involved. It is also
important that the therapist is able to identify the muscles
and soft tissues that are most prone to shorten and lose
extensibility. The following sections of this chapter discuss
the key concepts in the use of mobilising exercises in
management of soft tissue conditions.
Mobilising exercises are a fundamental component of
the rehabilitation process as they enhance normal tissue
healing and are necessary to load the soft tissues progres-
sively. Ultimately, the resultant scar tissue is stronger
(Melis et al. 2002) and this enables it to more effectively
withstand the stresses and strains it encounters during
normal functional use (Hunter 1998).
280
Mobilising exercises can be used to maintain or increase
range of movement, when restricted, for which the causes
are numerous. These causes include:
• contractures of the joint capsule;
• adhesions within the soft tissues;
• muscle spasm or tightness;
• neural sensitivity and inhibition caused by pain.
Physiotherapists often use mobilising exercises in con-
junction with other treatment modalities such as passive
movements, heat, electrotherapy and soft-tissue tech-
niques, depending on the presenting symptoms of the
client.
For the purposes of this chapter, exercises are divided
into the following classes:
• passive;
• active-assisted;
• auto-assisted;
• active;
• stretching (including hold/relax).
Classes of mobilising exercise
Passive exercises
Passive exercises can be defined as exercises by which
movement is produced entirely by an external force with
the absence of voluntary muscle activity on behalf of the
patient. This external force may be supplied by the thera-
pist (as is the case with passive movements) or by a
machine. For example, continuous passive motion (CPM)
units might be used following total knee arthroplasty or
other knee surgical procedures, or in stroke rehabilitation
(Lynch et al. 2005) to enhance recovery of the shoulder.
Passive exercises are typically employed in the early
stages of rehabilitation after the onset of trauma, provided
that affected structures are stable enough to sustain move-
ment without vulnerability to further injury, and provided
that the exercise is not unduly painful. They may also be
used to maintain range of movement in soft tissues during
periods of joint inactivity. They are commonly utilised in
conjunction with stretching exercises to further increase
the ranges achieved.
Active-assisted exercises
These are exercises in which the movement is produced
in part by an external force, but is completed by use of
voluntary muscle contraction. These exercises are of
obvious value when strengthening a weakened muscle, but
with the assistance given by the external force they can also
be used to increase range of movement while allowing the
individual to maintain control of the exercise.
Another important factor to be considered is gravity. If
the exercise is performed with assistance from gravity, this
may increase its effect on mobilising the targeted structure
(Figure 13.4).

A B
Figure 13.4  (a–c) Active-assisted shoulder elevation demonstrating the use of gravity and the other arm (via a pole) to gain
range of movement.
Equipment
All manner of equipment is used to facilitate active-
assisted exercises. Common examples are pulleys, slings
and pole exercises for shoulders, re-education boards for
knees and elbows, as well as many other external adjuncts.
The physiotherapist should be as innovative as required.
Auto-assisted exercises
These exercises can be either passive or active-assisted, as
described above, and occur when the external force is
applied by the individual rather than by the physiothera-
pist. This may be through use of exercise equipment,
for example shoulder mobilisation using auto-assisted
pulleys.
Active exercises
Also known as free active exercises, these are activities in
which the movement is produced solely by use of the
individual’s voluntary muscle action. They can be used as
either strengthening for grade 2 and above on the Oxford
scale (see previous) or to mobilise structures – as is the
case with dynamic stretching exercises.
Key point
With any exercise the correct choice of starting position
is important. For example, for a mobilising exercise aimed
at increasing range of movement, gravity may well need
to be counterbalanced or the body part positioned so
that gravity assists the movement. If an exercise is
performed against gravity it will have more emphasis
towards strengthening.
A clinically useful feature of active exercises is that they
can be performed without the use of equipment, so they
can be practised anywhere and can easily form the basis
of a home exercise programme.
Exercise in rehabilitation Chapter 13
C
Stretching exercises
If performed appropriately, stretching exercises may be a
simple, yet very effective, form of treatment. For example,
in the elderly a loss of hip extension during walking
implies the presence of functionally significant hip flexor
tightness (Kerrigan et al. 2001) and predisposes individu-
als to falls and subsequent femoral neck fractures. Over-
coming hip tightness with specific stretching exercises as
a simple intervention shows some improvement in
walking performance and possibly fall prevention in the
elderly (Kerrigan et al. 2003).
Stretching is commonly employed within the athletic
population. Increasing the range of motion available at
a joint has obvious advantages in increasing function
and performance. It is suggested that regular stretching
improves force, jump height and speed, although there is
no evidence that it improves running economy (Shrier
2004). It has also been suggested that it contributes to
injury prevention, although research does not suggest that
stretching reduces risk of injury or reduces the effects of
DOMS at present (Herbert and Gabriel 2002).
Key point
Stretching exercises are normally used to mobilise neural
and muscle tissue to the limits of the available range.
There are many forms of stretching exercise and
techniques commonly used in combination, therefore a
consensus as to their effects is difficult to ascertain
within the published evidence. Stretching will result in a
temporarily increased change in length but prior to
sporting activity, as part of a warm-up, it may be more
appropriate to use a technique that activates muscles, as
stretching may result in a reduction of muscle tone.
Stretching exercises are performed with the target struc-
ture moving towards a lengthened position. The stretching
exercise will involve further movement in this direction so
as to further lengthen the structure. Collagen fibres realign
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 Tidy’s physiotherapy

rapidly as a result of stretching forces and become aligned Dynamic stretching

(and therefore stronger) in the direction of the stretching
This involves gaining range by an active movement and
force (Melis et al. 2002). The limiting factors to further
should not be confused with ballistic stretching (see
movement, such as the degree of pain experienced, will
below) which involves the use of repetitive, bouncing,
govern the extent to which any further movement is pos-
dynamic, rhythmic movements performed at higher veloc-
sible. Stretches are commonly used to increase range of
ities. Dynamic stretching involves progressively increasing
movement by mobilising restrictions within soft tissue
the range through successive movements until the end of
(e.g. scar tissue) and are specifically used in the lengthen-
range is reached.
ing of tight muscles.
Dynamic stretching is especially useful when dealing
The time at which stretching is commenced after an
with more advanced sports-related rehabilitation prob-
injury needs careful consideration. After any soft tissue
lems. The exercises enhance dynamic function and
injury, the length of the immobilisation depends on the
neuromuscular control through repetition and practice,
grade of injury and must be optimised so that the scar can
thereby training motor patterning and enhancing the
withstand the longitudinal forces operating on it without
movement memory. If the patient is suitable, this form of
re-rupture. Mobilisation of soft tissues by stretching will
stretching can be highly effective to mobilise soft tissues
aid reabsorption of the connective tissue scar and recapil-
and enhance motor control.
larisation of the damaged area (Kujala et al. 1997).
Stretching may also be used as a preventative measure, Note on ballistic stretching
for example to prevent joint contractures. However, while
the primary intervention for the treatment and prevention Ballistic stretching uses repeated, successive movements
of contracture is to regularly stretch the soft tissues, and and momentum to gain range. The drawbacks to using this
the rationale behind this intervention appears sound, the type of exercise with most individuals encountered in the
effectiveness of stretching has not been verified with well- hospital setting are that patients are typically not condi-
designed clinical trials on subjects who have sustained soft tioned to use ballistic stretching effectively or without sus-
tissue injury (Shrier and Gossall 2000). One such trial taining further injury.
(Malliarapolous et al. 2004) looked at the frequency of During ballistic stretching, the stretch reflex is normally
stretching protocols in athletes with hamstring injuries initiated to resist the change in muscle length and to
and found a significant difference in rate of recovery when protect the muscle from injury. This occurs as a result of
the protocol was applied three times daily compared with stimulation of the non-contractile elements of muscle
once a day. However, a lack of control group limits our spindles, which send afferent information about the
insight into the effectiveness of this modality and a lack length of muscles to spinal cord level. In turn, this causes
of longer-term surveillance limits insight into its effect on stimulation of the extrafusal fibres via the alpha motor
reinjury rates. neurone, resulting in a muscle contraction.
Stretches may be applied in one of two ways: either It is suggested should this muscle contraction coincide
dynamically or statically (Table 13.5). with the next ballistic movement, a muscle unconditioned
to cope with that stress may become injured. As a result,
patients are normally instructed not to ‘bounce’ while
performing their stretching routines.
Table 13.5  Stretching exercises: A summary
Static stretching
Dynamic stretch Static stretch
As the name suggests, this involves maintaining a position
Feature Faster, rhythmic, Slow, controlled, for a sustained period to gain the desired effect – it is
of stretch higher velocity, emphasis on widely agreed that an effective time to hold a static stretch
technique motor control, postural is at least 30 seconds (Bandy et al. 1997). This gives time
functional awareness, for the muscle spindle to adapt to the new length and
bodily alignment will also result in an increase in functional length of
visco-elastic structures, such as muscles, albeit temporary
Duration Repetitive, Sustained
(Magnusson et al. 1998).
of stretch progressive 30-second hold
Static stretching is a controlled, slow movement with
Stage End-stage Early, middle emphasis on correct bodily alignment. Static stretching
employed rehabilitation and end-stage protocols are commonly used and, for example, have been
Training motor rehabilitation shown to be effective in terms of improving flexibility of
patterning muscle (Chan et al. 2001). An element of fine motor
control and postural awareness is important during static
Client Sportsmen, active All
stretching exercises and this can be enhanced by the use
types persons
of feedback and correction from the therapist, as well as

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 Exercise in rehabilitation Chapter 13

Key point

Correction of this type of exercise is frequently required

to ensure an effective stretch is produced in the targeted
tissue.

mirrors. Exercise forms such as pilates, Tai Chi and yoga

employ many of these principles and can be used effec-
tively within a patient’s exercise programme.
Therapeutic stretching or strengthening exercises are
successful only if the target muscle is properly isolated A
(Gluck and Liebenson 1997), particularly when the tissue
concerned crosses more than one body segment. Problems
are often encountered when stretching two joint muscles.
For example, when stretching the hamstrings, pelvic
alignment needs to be controlled, as well as considering
hip flexion and knee extension components, to stretch
effectively.
The order in which the components are added can also
influence the effect, depending on which area of the mus-
cle’s structure is to be targeted. For example, if it is required
to target the distal portion of rectus femoris, one may wish
to employ a stretch, which extends the hip then flexes the
knee, while proximally the components may be added
alternatively (Figure 13.5). B
It is also important to consider the functional anatomy
of the area being targeted, particularly when considering
Figure 13.5  Demonstrating the order effect of adding
the addition of rotational components to stretching exer-
components to a stretch of rectus femoris: hip extension then
cises. Using the hamstrings as an example, the medial knee flexion (a); knee flexion then hip extension (b). Note
hamstrings (semimembranosus and semitendinosus) that the lumbar spine should remain in neutral throughout.
would require a component of lateral rotation to stretch
them effectively. To effectively stretch biceps femoris an
element of medial rotation would be required owing to its Teaching stretching exercises: A practical guide
ability to act as a lateral rotator of the knee. Before performing the stretch:

Spinal position
Many upper and lower limb muscles at the scapular and
pelvis have their origins from the axial skeleton, so spinal
position can influence limb position. Consequently,
throughout many stretching exercises it is important to
consider any lumbo-pelvic, scapulothoracic or spinal
movement to ensure that it is controlled throughout the
exercise. Where possible there should be no spinal move-
ment, ensuring a ‘neutral’ posture is maintained through-
out. The ‘neutral’ position being the position of optimal
alignment and stability (Richardson et al. 2004). For
example, in the lumbar spine this would equate to a
slight curve in the lumbar lordosis convex anteriorly and
in the cervical spine, again, a slight cervical lordosis with
a right angle between the mandible and anterior neck.
The spine would then be maintained in this position
for the duration of the stretch to prevent unwanted
spinal movement and potential limitation of treatment
effectiveness.
• ensure that your assessment has not identified any
contraindications to stretching;
• ensure that there is a logical, reasoned basis for your
stretching programme, e.g. if there is a bony block to
movement caused by osteophytes, stretching is not
appropriate (refer to Chapter 11 on ‘end-feel’);
• explain how and why they are performing the stretch
to ensure maximum compliance and benefit;
• explain to the patient what they should experience
during the treatment, i.e. how far to stretch, degree
of discomfort to expect;
• consider how the stretch might be made more
comfortable prior to stretching (e.g. use of a hot
pack or hydrotherapy).
During the stretch:
• maintain spinal position in neutral throughout, if
appropriate;
• patient to perform stretch across all joints at the
same time for two or more joint muscles;

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 Tidy’s physiotherapy
• make the stretch slow and sustained – do not
bounce;
• the patient should experience a pulling sensation,
not pain;
• hold the position for at least 30 seconds;
• if tension releases, take the movement a little further;
• release slowly.
After the stretch:
• warn the patient what feelings to expect following
the stretch;
• remember that once movement has been regained,
active muscle control throughout that range will be
needed, as well as some form of maintaining the
stretch in the long term.
Contraindications to stretching
These are some of the contraindications to stretching:
• bony block or end-feel to movement on passive
assessment of the joint in question;
• recent or unstable fractures;
• acute soft tissue injuries;
• the presence of infection or haematoma in the
tissues;
• after some surgical repairs and other procedures,
such as skin grafting and tendon repair;
• patient refusal.
Key point
Although static stretching is widely believed to cause an
increase in a muscle’s functional length, recent
investigations suggest otherwise. It has been suggested
by Magnusson et al. (1998) that the visco-elastic
properties of muscles remain unaltered in the long term
following stretching and that it is the muscle’s tolerance
to stretch that is increased. Such details, along with
further developments in the area, need to be considered
when prescribing stretching exercises.
Hold/relax techniques
Proprioceptive neuromuscular facilitation (PNF), also
commonly referred to as hold relax and contract relax, can
have effective results when trying to mobilise muscles.
PNF stretching techniques may produce greater increases
in range of motion than passive, ballistic or static stretch-
ing methods (Spernoga et al. 2001). PNF is a form of
treatment devised to manually rehabilitate movement in
specific patterns using a number of physiological princi-
ples to enhance its effectiveness.
A core principle of PNF is that after a muscle has
contracted maximally it will then relax maximally. This
284
principle can be used when using exercises to mobilise
muscles which are in a shortened position. The patient is
asked to contract the tight muscle strongly and hold the
contraction isometrically for around 10 seconds, then
relax. Following a short period of 2–3 seconds the physi-
otherapist then applies a stretch to the muscle, which is
maintained for 30 seconds. Following a period of recovery
this sequence is repeated.
Another useful principle used in PNF is that of reciprocal
inhibition, which states that when a muscle (the agonist)
contracts maximally, its opposite counterpart (antagonist)
will relax maximally. This can be used by asking the
patient to maximally contract the agonist to the muscle to
be mobilised followed by application of a stretch.
This principle of reciprocal inhibition can also prove
useful and is worth considering during static stretching
exercises where a contraction of the muscle’s antagonist
can act to relax and lengthen it.
PROGRESSION OF EXERCISE
An exercise programme without planned progression will
quickly become ineffective. It is essential to review the
exercise programme regularly and revise it to match the
patient’s status. There are various ways to progress exer-
cises, including:
• changing the starting position;
• changing the length of the lever;
• changing the speed at which the exercise is
performed;
• altering the range through which the movement is
performed;
• applying resistance.
The starting position
Changing the starting position may change the base of
support and may affect the difficulty of an exercise. Reduc-
ing the base of support will normally have the effect of
advancing the difficulty of the exercise from a neuro­
muscular control perspective and vice versa. For example,
performing an exercise while standing on one leg will
require more hip abductor control than when standing
on two legs.
A change in starting position can also change a body
segment’s relationship to gravity, which will change the
nature of an exercise. An exercise performed against gravity
will require concentric muscle work and eccentric work to
return to the starting position – it will, therefore, be a
strengthening exercise.
With more grossly weakened muscles (Oxford scale
2 and below), exercises performed in a gravity-
counterbalanced position will be more effective. Exercises
 Exercise in rehabilitation Chapter 13

performed in this position will also be more effective in

mobilising structures.
If an exercise is performed with the assistance of gravity
it may have a strong mobilising effect upon reaching the
end of the available range of movement owing to the
weight of the body part. An example of this is performing
squats from a standing starting position to increase the
range of knee flexion, using the effects of gravity and body-
weight to increase knee flexion (Figure 13.6) and ankle
dorsiflexion (Figure 13.7). Another example is shoulder
flexion in lying and standing (Figures 13.8–13.10).

Length of the lever

Changing the length of the lever will affect the forces Figure 13.8  Shoulder flexion in lying.
applied to the body during exercise (see Figures 13.11
and 13.12).
A lengthened lever will result in a higher force being
exerted at the fulcrum of the movement, so more muscle
work will be needed to produce or control the movement.

Figure 13.9  Shoulder flexion in lying.

Figure 13.6  Static stretching of the right hip adductors.

Figure 13.10  Shoulder flexion in standing. Gravity resists the

movement throughout the range in standing even though
Figure 13.7  Using gravity to mobilise ankle dorsiflexion. the movement is the same as in Figure 13.9.

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 Tidy’s physiotherapy
Figure 13.11  Shoulder abduction with a shortened lever.
Figure 13.12  Shoulder abduction with a long lever.
The muscle work of shoulder abduction is greatly increased
by increasing the lever length.
Figure 13.13  A resistance exercise to strengthen shoulder
extensors.
286
This will also result in a higher force applied to structures
during mobilising exercises.
Levers may be shortened or lengthened by flexing or
extending joints, most commonly the elbow or knee
joints. They may also be lengthened by holding or attach-
ing an object to the end of a limb, such as holding a weight
at arm’s length.
The positioning of the application of resistance along
the lever will also affect the muscle work required. Resist-
ance applied distally will require more effort and will
reduce when the same resistance is applied more proxi-
mally. In mobilising exercises a resistance applied distally
on the lever will have a greater mobilising effect than
resistance applied proximally.
Speed of movement
A change in the speed at which a movement is performed
will change the nature of an exercise. When altering the
speed, the physiotherapist must be clear as to the desired
effect. An exercise performed slowly requires a great deal
of precision and postural control. An exercise performed
at higher velocities will produce a greater mobilising effect
at the end of range, but the client will require adequate
neuromuscular control to perform this without risking
further injury.
Range of movement
A change in the range through which an exercise is per-
formed will alter its difficulty. Muscles are at their strong-
est in middle range and weakest in outer range (a more
lengthened position). This is discussed in more detail in
the context of muscle strengthening exercises.
Resistance to movement
The final way to progress an exercise is to apply resistance
to strengthen a muscle (see Figure 13.13). Resistance can
be applied in a number of ways. These are related to the
desired effect – whether the aim is to produce a change in
power or in endurance, as discussed.
DEALING WITH MOVEMENT
DYSFUNCTION
When dealing with movement dysfunction we are inter-
ested in the kinetic chain, a series of successive joints or
segments, and the way each segment’s movement and ori-
entation influences the rest. Movement dysfunction can
give rise to acute muscle strain (Emery 1999) and overuse
injuries owing to abnormal stresses caused by abnormal
movement patterning. When patients present with symp-
toms resulting from movement dysfunction exercise is
 Exercise in rehabilitation Chapter 13

used to rehabilitate them. Sahrman (2002) states that CNS

either maintenance or restoration of precise control of
each segment is necessary to manage pain of musculoskel-
etal origin. To learn more about dealing with movement
dysfunction and muscle imbalance refer to Chapter 14. Visual Afferent Efferent
vestibular feedback response

REHABILITATION OF SENSORIMOTOR
CONTROL Proprioceptive Neuromuscular
information response
– Muscle
Exercises aimed at accessing   – Cutaneous
– Joint
the sensorimotor control loop  
to develop and enhance   Figure 13.14  Diagrammatic representation of the
mechanism of sensorimotor control.
movement control
Introduction
Table 13.6  Conditions commonly exhibiting reduced
Normal proprioception is essential to everyday function- proprioception
ing, whether it involves simply placing a cup on a table or
running around a football field. Definitions of propriocep-
Proprioceptive Clinical example
tion have been the cause of some debate within the litera-
deficits identified in
ture, as proprioception is only a part of the process of
sensorimotor control. Therefore, some authors include the Osteoarthritis Particularly joint
motor response, as well as the initial sensory input within degeneration in the lower
their definition. limb, the knee encountered
most commonly

Ageing Any elderly patient

Definition
Proprioception is ‘specialised variation of the sensory
modality of touch and encompasses the sensations of
joint movement (kinaesthesia) and joint position (joint
position sense)’ (Lephart and Henry 1995).
The above definition implies that proprioception is very
much an afferent (sensory) response. However, motor
response has also been incorporated into other definitions
of proprioception (Jerosch and Prymka 1996) and prop-
rioception is an example of afferent input entering the
CNS (Figure 13.14).
Physiotherapists are concerned with the normal func-
tioning of this afferent response, but more importantly it
is the efferent (motor) response to this sensory input that
physiotherapists are most involved with from a rehabilita-
tion point of view.
Loss of proprioception is a commonly encountered
clinical problem and disturbs the continual feedback
of accurate afferent information, and therefore has a
knock-on effect on motor control. The key areas where
proprioceptive deficits have been identified through
research are presented in Table 13.6. The first column in
the table illustrates the importance of being aware of the
potential scope of proprioceptive loss and how important
Immobility Patients on bed rest or
immobilised owing to
illness or trauma
Trauma Anterior cruciate ligament
injuries, glenohumeral
dislocation and instabilities,
lateral ligament injuries of
the ankle
Key point
Proprioception could also play a vital role in prevention
of injury, as well as in reducing symptoms of pathology.
Caraffa et al. (1996) found a sevenfold reduction in
anterior cruciate ligament injuries in a group of 300
semi-professional and amateur footballers who
undertook a proprioceptive training programme when
compared with a matched control group.
appropriate sensorimotor rehabilitation is with a large
percentage of patients. It is primarily the muscle spindles
that play a significant role in providing afferent proprio-
ceptive feedback during movement (Proske 2005). It is the
articular receptors that provide more information in outer

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 Tidy’s physiotherapy
Table 13.7  Examples of receptors and their functions
Receptor Type
Ruffini end organs Slowly adapting
Pacinian corpuscles Slowly adapting
Muscle spindles Rapidly adapting
Golgi tendon organs Slowly adapting
range when the structures in which they are embedded are
put on stretch (Jerosch and Thorwesten 1998). It has also
been hypothesised that proprioceptive deficiency could,
in fact, precipitate degenerative joint changes (Barrett
et al. 1991).
The mechanism of proprioception
There are many receptors within joints, muscles and skin
that continually convey information to the CNS. Using
this information we continually make subconscious and
conscious modifications to how we move, allowing us to
carry out normal functional activities. Each receptor sup-
plies a different type of information, for example joint
pressure, joint acceleration/deceleration and joint velocity.
When the receptors are stimulated through movement or
other forces, they act as transducers and convert this
mechanical deformation into an electrical sensory impulse
(Barrack et al. 1994). This sensory impulse then passes on
to the CNS, triggering the appropriate motor response.
When walking on uneven ground, for example, the
muscles of the lower limb continually have to adjust in
order to keep the body upright and prevent a fall. The
peronei and anterior tibialis, for example, will be continu-
ally controlling the movement of the foot and ankle,
responding to constant positional changes the gluteals
will also be performing a similar function at the hip joint.
This example illustrates the nature of proprioception as a
continuous process occurring at different levels of the CNS
at the same time.
When rehabilitating sensori-motor control we need to
take the task from the conscious into the sub conscious
level to function normally. In early stages of rehabilitation
we need to re-educate sensory and motor pathways, and
movement tends to be very deliberate but as the patient
begins to improve, we can start bombarding the CNS with
other sensory information and motor tasks to achieve this
subconscious level of control. For example, once the
patient is able to balance on a wobble board we can then
give them other tasks to do such as throwing a ball while
maintaining balance.
Receptors, as well as having different functions, also
have different properties. For example they may react at
288
Function
Monitoring position of the limb in space
Detection of acceleration and deceleration or sudden
mechanoreceptor deformation
Changes in muscle length
Changes in muscle tension
different speeds and can be rapidly or slowly adapting
(Barrack et al. 1994; Borsa et al. 1994). The impulse from
a rapidly adapting receptor drops off quickly, whereas that
from a slowly adapting receptor fires for longer periods.
Some examples are presented in Table 13.7.
Importantly, many joint receptors are also only active at
the beginning and ends of range. Therefore, as a joint
moves through a range of movement it is reliant on other
receptors to keep the CNS informed of its activity. Particu-
larly important in maintaining this function are the
muscle spindles (Figure 13.15).
The large volume of proprioceptive information enter-
ing the CNS is utilised at three different levels.
• Spinal level. Reflex contractions occurring at this level
contribute to reflex stability within a joint, helping
to reduce the risk of injury from sudden forces acting
on the joint.
• Brainstem. This is the part of the brain which receives
input from the vestibular centres in the eyes and ears
and helps to control balance.
• Motor cortex, cerebellum and basal ganglia. Responsible
for control of complex movement patterns.
Instability
The word ‘instability’ is frequently encountered when
dealing with patients who display reduced proprioception.
Instability can effectively be divided into two types.
• Structural (mechanical) instability. Disruption of the
passive control system (articular and ligamentous) of
a joint results in instability. This is the type of
instability detected by manual testing, for example
valgus stress testing at the knee to test the medial
collateral ligament or an anterior drawer to test for
shoulder instability.
• Functional instability. Passive control systems are
intact with no laxity detected through manual
testing. The patient will, however, complain of
symptoms such as ‘giving way’ (lower limb) or ‘pain’
and ‘dysfunction’ (upper limb). The problem is one
of poor neuromuscular control and was initially
described by Freeman et al. (1965) with reference to
ankle inversion injuries.
 Exercise in rehabilitation Chapter 13

Tendon
Nerve terminals
weaving between
collagen fibres Nerve to
muscle

Fibrous capsule γ - motor

Muscle α - motor nerves to
of Golgi tendon neurones
belly extrafusal muscles
organ neurones
Tendon Group Ia Sensory
Group II fibres

Myelin
sheath
Nerve bundle
Group Ib Tendon to spindle
afferent fibre
Extrafusal
Annulospiral fibre
endings

Extrafusal Flower spray

fibre ending

Connective Nuclear
sheath of bag fibre
spindle
Nuclear
chain fibre

A B Intrafusal fibres

Figure 13.15  (a) The Golgi tendon organ and (b) the muscle spindle.

The above definitions illustrate the fact that joint stabil-

ity is multifactoral and relies significantly on dynamic, as
well as passive, control (Waddington and Shepherd 1996).
This is a key point and has major implications for the
rehabilitation process. Functional instability is, however,
the type of instability most commonly encountered by
physiotherapists. Work on ankle injuries has shown that
the majority of patients suffer from functional instability
only (Richie 2001). The potential causes of functional
instability are presented in Table 13.8.
Correcting functional instability is the primary aim
during functional rehabilitation (Lephart et al. 1997) and
it is particularly important before undertaking rapid
dynamic activities, such as sudden deceleration, which are
seen in many sports, but, just as importantly, may also be
seen in many occupations.
It is possible in some situations to reduce or even allevi-
ate the symptoms of structural instability through appro-
priate neuromuscular training. More often a referral for
surgery may be necessary to correct the structural defect.
If functional instability is not addressed, chronic injury
syndromes can develop.
Key point
Individuals suffering from structural instability are also
likely to develop functional instability – a breakdown in
the sensorimotor control loop results in lack of muscular
control around the joint. Those suffering from functional
instability can eventually develop structural instability
owing to abnormal movement patterns placing excessive
loads on the body’s tissues.
Assessing proprioception
Assessment of proprioception takes several forms, many
of which rely on complex equipment, such as force plates
or isokinetic dynamometers. Force plates can measure
postural sway and, therefore, adaptive responses to move-
ment tasks. Isokinetic dynamometers can measure the
threshold of detection of passive movement, for example
in the shoulder complex the blindfolded subject needs to
indicate when they sense movement in the glenohumeral
joint. This value can be compared with the unaffected side.

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 Tidy’s physiotherapy

Table 13.8  Potential causes of functional instability within a joint

Cause Rationale Reference

Articular Articular mechanoreceptors are damaged, reducing the afferent impulse Freeman et al.
de-afferentation to the CNS, resulting in a decreased motor response (1965)

Differentiation Trauma can result in direct damage to the motor supply, resulting in a Wilkerson and
decreased muscular response to perturbation Nitz (1994)

Neurogenic Thought to be related to joint inflammation and inflammatory mediators Wilkerson and
inflammation directly affecting the motor endplate and therefore the motor response Nitz (1994)

Capsular Joint effusion following trauma can cause muscle inhibition, leading to Wilkerson and
distension instability Nitz (1994)

Similarly, subjects can be asked to position the affected

limb in the identical position as the opposite one or asked
to reproduce a movement on the same side, again meas-
ured on the isokinetic dynamometer. There is, however,
currently a lack of validated tests that can be used easily
within the clinical setting.

REHABILITATION OF SENSORIMOTOR
CONTROL OF THE LIMBS

Issues
The key aims of rehabilitation to sensorimotor control are:
• to provide early afferent input to a joint – this will
limit further damage and reduce further losses
through inactivity;
• to restore reflex stability – this is the coordinated,
co-contraction of all stabilising muscles around a
segment when called upon to move;
• to restore normal neuromuscular coordination – this
is the correct sequencing of muscle activity necessary
to perform normal movement;
• to enhance the neuromuscular response to facilitate
control through the sensorimotor control loop.
Early commencement of proprioception can sometimes
be neglected in rehabilitation. In the case of the lower
limb, when partial weight-bearing at least is sometimes
incorrectly seen as a prerequisite of proprioceptive train- Figure 13.16  Wobble board work in sitting.
ing. Wobble board work in sitting is an exercise that can
be started early and progressed (Figure 13.16). Sensorimo- There is a wide variety of equipment available to facili-
tor control exercises need to be functional and are usually tate rehabilitation of the sensorimotor system. There are
a combination of open and closed kinetic chain exercises. numerous types of balance boards, starting with simple
Closed kinetic chain exercises are useful in that they gain unidirectional rocker boards to swiss balls. Wobble boards
co-contraction of stabiliser muscles and hence segmental are a good way of bombarding the CNS with afferent
control, and in the fact that they give high quality proprio- input in the early stages of rehabilitation, but they are not
ceptive feedback as the fixed distal segment gives a refer- a functional piece of equipment and it is important to
ence point for the CNS to work from. progress from these types of apparatus as required. Other

290

equipment, such as low friction surfaces, can be useful
acquisitions to enhancing dynamic functional stability. It
should also be borne in mind that this equipment could
be used just as effectively in the upper limbs as in the lower
ones. The only limit to devising proprioceptive exercises
should be your imagination.
There are several means available to the physiotherapist
to progress proprioceptive exercises. These include:
• removing visual stimulus;
• altering the base of support;
• increasing weight-bearing;
• increasing speed of an activity;
• making an exercise more complex, e.g. adding
perturbation (an unexpected external force, e.g.
a push).
Visual input provides additional afferent input to the
CNS. Without it any given exercise becomes more difficult
to perform as the subject will have to rely more heavily on
proprioceptive information, even with wobble board
activities in sitting.
An example of altering the base of support is illustrated
in Figure 13.17. This activity progressively requires greater
neuromuscular control and strength to maintain a given
position.
A A
B B
Figure 13.17  (a, b) Altering the base of support with motor
control exercises.
Exercise in rehabilitation Chapter 13
Key point
It is important during rehabilitation to place the joint(s) in
situations that encourage the necessary reflex stability
required to meet the functional demands of the
individual. Stability work should therefore be progressed
to place joints in more challenging and functional
positions.
The lower limb
Proprioceptive exercises in the lower limb in the early
stages of rehabilitation are progressions towards full
weight-bearing. In the latter stages, more dynamic stop–
start activities that require aspects of eccentric control with
acceleration, deceleration and strong reflex stability
around the ankle and knee can be added. As detailed
above, they can be progressed in several ways (see section
on progression of exercise).
Figure 13.18 illustrates a typical exercise for the lower
limb. It is important to remember that this is not a par-
ticularly functional exercise as the limb remains static, so
Figure 13.18  Maintain contraction during lower limb
movement.
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 Tidy’s physiotherapy
B
Figure 13.19  Eccentric control of hip extension using rubber
tubing. The speed of the exercise and resistance of the
tubing can be changed to suit the aims of the exercise and
increase specificity.
will require progression by the end-point of rehabilitation.
The more dynamic activities outlined above can be
described as proprioceptive as they stress the joints in
challenging positions and encourage the reflex actions
that are required.
The upper limb
Key point
The objective of proprioceptive rehabilitation is to
‘enhance cognitive appreciation of the respective joint
relative to position and motion, and to enhance muscular
stabilisation of the joint in the absence of structural
restraints’ (Borsa et al. 1994).
292
Figure 13.20  Example of lower limb motor control exercises.
The above quotation refers to rehabilitation of unstable
shoulders and perhaps highlights the potential differences
in the nature of pathologies between the upper and lower
limb. The shoulder is inherently more unstable than the
joints of the lower limb and is therefore much more vul-
nerable to mechanical, as well as functional, instability.
Consequently, a comprehensive assessment needs to be
undertaken when rehabilitating the shoulder to ascertain
the exact cause of the problem.
Owing to this potential level of instability, close-chain
exercises are often a useful starting point, as they help
to encourage joint stability through co-contraction of
the surrounding muscles induced by the axial compres-
sion (Davies and Dickoff-Hoffman 1993). Variations
of the four-point kneeling position are commonly used
to achieve this (Figure 13.17). These positions are also
useful in rehabilitating scapula stability, which will also
be affected with (or be a cause of) many shoulder
problems.
When rehabilitating older patients or those with a
poorer physical condition, four-point kneeling may not
be an appropriate position and variations of closed-chain
exercises can be used. These can include resting the hand
on a wobble board in sitting or resting the hand against a
 Exercise in rehabilitation Chapter 13

wall or table to allow a degree of weight-bearing and then

moving the shoulder.
The reflex stabilisations can also be used and are aimed
at eliciting the correct motor response at the appropriate
speed and in the most functional position. These consist
of a sustained isometric contraction in a specific range in
the joint’s motion with the scapula in the correct position.
These particular exercises and variations of them could be
used with an athlete who would require shoulder stability
in a vulnerable position, for example a rugby player when
making a tackle.
Once a degree of control has been restored, more func-
tional exercises can be taught. These may be occupation-
or sports-specific to ensure the patient can withstand the
stresses they encounter during their lives.
Rehabilitating the sensorimotor system requires ade-
quate strength and endurance within the muscle. Many
of the exercises illustrated can also be viewed as streng­ Figure 13.21  Swiss ball exercise designed to develop
thening exercises. Although much of the preceding neuromuscular control around the trunk.
discussion has emphasised sensorimotor rehabilitation in
isolation, the need for an accompanying strength and
endurance programme is paramount. Indeed, muscular
fatigue has been shown to induce proprioceptive deficits
(Voight et al. 1996).
There is no definitive way to rehabilitate the sen­
sorimotor system and issues of progression depend on
functional need, pain, swelling and an appropriate
strength base.

REHABILITATION OF SENSORIMOTOR
CONTROL OF THE SPINE

The spine needs an effective neuromuscular control

system and also benefits from sensorimotor control
rehabilitation. The term ‘core stability’ is used with refer-
ence to back rehabilitation – ‘core’ referring to the trunk
as the central control point of all movement. Research
has shown that the muscles that stabilise the spine can
become defacilitated and wasted (Hides et al. 1996) and
have delayed recruitment during functional movements
(Hodges and Richardson 1996). Loss of control of the core
is hypothesised to lead to loss of segmental stability owing
to loss of core stability mechanisms. These mechanisms
include increasing of intra-abdominal pressure (Cresswell
et al. 1992) and a stabilising effect through tensioning the
thoracolumbar fascia (Hodges and Richardson 1997). If
core stability is impaired it could have a detrimental
effect on many other anatomical structures along the
kinetic chain. This may be proximally in the pelvic and
shoulder girdles, or more distally in the limbs. Dynamic
postural control requires reflex stabilisation of the
trunk muscu­lature that controls core stability. Specific
transversus abdominus and multifidus re-education is
Figure 13.22  Swiss ball exercise aiming to integrate trunk
and hip control.
required, and progressed into dynamic movements and
then function. The emphasis on maintaining a neutral
spinal position during exercise is necessary (Panjabi
1992), thus reducing shear forces around the spinal seg-
ments and facilitating stabiliser activity. Swiss-ball exer-
cises are commonly used to help restore this dynamic
control (Figures 13.21 and 13.22).
Key point
Panjabi (1992) uses the phrase ‘clinical instability’ when
referring to a decrease in the effectiveness of the passive
and dynamic stabilisers within the spine.

293
 Tidy’s physiotherapy

Conscious appreciation of spinal position and associ-

ated muscle activity has been aided by the use of
equipment such as the Stabiliser pressure biofeedback
device (Chattanooga, Australia). This is a simple device
consisting of an air-filled chamber and an attached
dial that monitors pressure changes. Patients are instructed
to perform exercises while maintaining a constant pres-
sure reading or altering the pressure through exercise.
(Figure 13.23).
Pain is often the major concern in these patients and a
neuromuscular training programme will aim to decrease
or alleviate pain. The mechanisms of spinal pain are,
however, varied and often poorly understood.
Core stability should not be confused with core strength,
as is commonly the case. Core stability refers to a level of
low threshold activity in the trunk stabiliser muscles,
which results in functionally stable sensorimotor control
of the trunk. Core strength refers to the effective produc-
tion of torque in the trunk muscles and does not relate to
finer levels of sensorimotor control. To read further on
core stability see Chapter 14.

Figure 13.23  Pressure Biofeedback maintain correct degree

of deep abdominal contraction.

B
Figure 13.24  Pole rotation resisted by rubber tubing to
enhance trunk control. Figure 13.25  (a, b) A plyometric drill for the lower limb.

294
 Exercise in rehabilitation Chapter 13

PLYOMETRIC EXERCISES

Plyometric exercises are normally incorporated in the

later stages of a rehabilitation programme and are aimed
predominantly at those individuals who require more
dynamic neuromuscular control and force generation as
part of their normal functional activities, for example ath-
letes. Plyometrics are also used as part of athletes’ training
programmes, as they have been found to enhance per-
formance (Sinnett et al. 2001, Swanik et al. 2002).
Plyometric exercises utilise the stretch-shortening cycle
to produce an enhanced concentric contraction. A plyo-
metric activity consists of a rapid eccentric contraction A
followed by an immediate concentric contraction. Typi-
cally, these exercises are performed in the lower limb and
involve various jumping-type activities. They can also be
performed in the upper limb. Successful performance
involves a rapid change from the eccentric to the concen-
tric contraction. The time between the eccentric and con-
centric contractions is known as the amortisation phase
– the quicker this phase the more powerful the muscular
concentric contraction.
Consider the jumping activity shown in Figure 13.25.
As the feet hit the floor the knees flex and result
in a stretch in what is known as the series elastic com­
ponent. The series elastic component consists of three
structures:
B
• Z lines;
• myosin hinges;
• Sharpey’s fibres (located at the site of tendon
insertion into bone).
Acting together, the series elastic components behave
like an elastic band that is stretched quickly – it stores up
energy that can be suddenly released. This energy is added
to the stretch reflex that occurs in the quadriceps on
landing and, together with the following concentric con-
traction, combines to provide a more powerful contrac-
tion. This type of activity is utilised in sport particularly in
the running gait cycle.
Plyometrics are used in the upper limb and certainly
have functional applications. Medicine-ball drills are often
incorporated into upper-limb exercises, as are activities
with rubber tubing. Medicine ball work can involve paired
throwing activities or use of a trampoline (Figure 13.27). C
The stated benefits of plyometric exercise are:
• increased power of muscular contraction; Figure 13.26  Plyometric drill using a trampette.
• enhanced neuromuscular coordination.
Before deciding to use plyometric exercises in the clini- Despite the emphasis of plyometrics being on advanced
cal situation, this checklist should be considered: rehabilitation, it can also play a role in improving the
• Is the person free of pain? neuromuscular response following injury.
• Is there an absence of recurrent swelling? Latency of contraction is commonly seen in muscles
• Does the person demonstrate a sufficient level of following an injury, for example the peronei in an ankle
stability? sprain. Using rubber tubing, the principles of plyometrics

295
 Tidy’s physiotherapy
A involve working with large loads, working in challenging
B son’s requirements and devise a rehabilitation programme
C tation and plays a major role in determining an individu-
Figure 13.27  Example of a timed circuit.
can be used to work on improving the neuromuscular
response and strengthening the peronei at the same time.
The patient takes the strain on the rubber tubing, holding
the foot in an everted position. The patient is then
instructed to release the tension on the rubber and then
immediately evert the foot again. The condition of the
ankle needs to be carefully assessed before commencing
this type of exercise, in the same way as the inclusion
criteria are checked for weight-bearing exercises. Similar
activities could be used in the upper limb for shoulder
medial rotators (Swanik et al. 2002).
There is little information on the number of repetitions
that should be completed with plyometric exercises. Foot
contacts have been suggested as an effective way of meas-
uring the intensity of activity (Tippet and Voight 1995)
in lower limb exercise, with a beginner counting 75–100
foot contacts and progressing up to 200–250 of low-to-­
moderate intensity. No values have been stated for the
upper limb. Common sense should also prevail in moni-
toring performance, looking out for loss of quality of per-
formance, obvious fatigue and an increase in length of the
amortisation phase, etc.
Plyometric exercises should be performed no more than
2–3 times per week. The eccentric component is likely to
cause a degree of DOMS and the muscle will need ade-
quate time to recover.
FUNCTIONAL TESTING   specificity. Once the tasks are established it is necessary to
AND REHABILITATION
All rehabilitation should be geared towards a return to
normal functional activity. Towards the later stages of
rehabilitation, the functional aspects are, perhaps, of
greatest importance.
296
Rehabilitation should not be measured as complete
solely by outcomes such as bilateral symmetry of strength
and range of movement, or an individual’s pain scores, but
on their return to full function – whatever that might be.
The physiotherapist needs to have a clear insight into the
specific vocational, occupational, sporting and functional
requirements of an individual to make sure the person is
rehabilitated to the correct level. Such demands may
environments or playing professional sport. The challenge
for the physiotherapist is to have an insight into that per-
to meet those specific needs.
Functional testing is an extension of functional rehabili-
al’s ability to return to pre-injury levels. This can take the
form of one particular drill that encompasses several of
the most difficult aspects of the individual’s occupation or
sport. For example, a soccer player needs to be able to run
quickly, accelerate and decelerate, change direction and
jump. A circuit could be set up to test any number of skills.
This circuit could be timed over a number of sessions to
determine improvement or may simply be used as a
one-off test to determine a return to full training. Tests will
be specific to their requirements, for example in sport they
may want to test strength, endurance or agility depending
on the specific nature of the sport or even be position-/
role-specific.
Functional tests can be used as a measure of progress
and are commonly employed as a requirement for
return to work in physically challenging occupations or a
return to play in sport. A functional test will establish a
baseline to measure future improvement, identify risk
factors predisposing to injury or reinjury and provide
motivation to the individual as it is a measurable outcome.
When assessing functional tests, the individual’s ability to
be able to respond to and tolerate functional demands is
observed. The way the body part contributes to the body’s
overall movement and sensorimotor performance is also
assessed.
There are several validated and widely used functional
performance tools in existence but it may be necessary to
design a functional test. If this is the case careful planning
is required. The first consideration is to identify the appro-
priate task, whether it is of a strength, endurance, motor
control or sports-specific nature. It will then need to be
decided in what environment the task needs to be per-
formed in – replicating functional environments enhances
plan how they will be measured and what equipment will
be required for this, for example video, surface electromy-
ography or a stopwatch. Once the planning has been com-
pleted all that remains is to perform the test, collect,
analyse and interpret the data. Analysis should consider
performance of all phases of the whole task, for example
video analysis should include observation of starting

Key point
When devising functional tests it is useful to apply the
SMART principle: specific, measurable, achievable,
realistic, timed. In this way, they can be developed as a
valuable objective measure. There is a large scope for
development of such tests, but it is also important that
once such tests are devised they are seen to be reliable
and valid.
position, preparatory position, approach, execution of the
task and termination of activity, for example landing.
Once the task has been analysed all that remains is inter-
pretation and analysis on how the individual has shown
improvement and if this is sufficient to withstand the
rigors of return to competition or work.
Functional rehabilitation allows a more objective
measure of fitness to return to work. However, unless
working in a specialist sporting environment or occupa-
tional centre such as an army rehabilitation centre, being
able to completely duplicate a particular working environ-
ment as described above may not always be possible. In
this situation, the physiotherapist needs to be inventive
A B
Figure 13.28  The sit-to-stand functional test. An example of a simple functional test requiring no equipment.
Exercise in rehabilitation Chapter 13
and reproduce the tasks to be undertaken in the working
environment as closely as possible, using any equipment
or apparatus that may be available. This can include
benches, wall bars, air cushions, rubber tubing, rucksacks
and sports-specific equipment.
Functional testing does not always need to be used as a
measure for determining return to full function; instead,
it may be used as a baseline measure of functional ability.
Examples of this include the various timed and distance
hop tests which are used to test ACL-deficient knees.
Tippet and Voight (1995) suggest the following times
when functional testing is undertaken within a sports
environment:
• pre-season training;
• during rehabilitation;
• immediately after injury.
Although the examples highlighted above involve quite
dynamic activities, functional testing and rehabilitation
can be applied to all populations. An example of func-
tional testing in the elderly population is the sit-to-stand
test (Figure 13.28) or a walk of fixed distance. This can be
either timed or judged on the number of repetitions.
Functional testing also provides psychological, as well
as physical benefits, not only in confirming progress but
improving confidence levels. It must be remembered that
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 Tidy’s physiotherapy

there is no substitute for ‘live’ conditions, such as perform-
ing in front of a hostile crowd, and functional testing can
only go so far in preparing individuals for full function.
GROUP EXERCISE
Group exercise sessions are used widely, especially with
more recent moves towards physiotherapists working in
primary care as part of their educational or advisory role
(Crook et al. 1998). Group work can take the form of
exercise classes in a gym, in a hydrotherapy pool or as part
of an educational programme during which patients not
only exercise but are also informed about the nature of
their condition (Figure 13.29).
Educational programmes are commonly employed with
the more longstanding pathologies and they encourage
patients to take responsibility for the continued manage-
ment of their condition (e.g. back education programmes
or osteoarthritis knee schools).
There are both advantages and disadvantages to group
work (Table 13.9).
Benefits and drawbacks
Provided that members of a group are carefully selected
there are several advantages to treating patients in groups.
Exercising with patients who have experienced similar
problems can provide peer support, encouragement, reas-
surance and camaraderie. It is also more economically
effective with the therapist able to supervise several people
at once.
The disadvantages of group work are that certain indi-
viduals may not respond to the group environment. In
particular, they may be embarrassed or dislike the interac-
tion. Many clients will respond better to individual atten-
tion from their therapist, particularly in the early stages of
rehabilitation; this is not possible in group work.
If groups are used solely as a way of treating large
numbers of patients with diverse pathologies they will
prove ineffective. This factor, along with a poorly organ-
ised treatment session, could lead to demotivation. There
need to be clear objectives and goals for each class, with
defined inclusion criteria.
Finally, it is important that participants in the group do
not become too competitive, thereby reducing the effec-
tiveness of the exercise and also risking further injury.
Planning group work
Careful planning is necessary if group work is to be effec-
tive. The aims of the group session must be clearly planned
and stated so that selection criteria for participants can be
agreed. This will ensure the session is both safe and effec-
tive. Factors such as age, gender, psychological status, the
stage in rehabilitation, past medical history and general
fitness need to be considered. The facilities and equipment
that are available need to be appropriate for the activities
planned. Important considerations are the space available
and the layout and temperature of the room or gym, not
only to provide a suitable environment but also a safe
place to exercise.
Table 13.9  Advantages and disadvantages
of group exercises
Advantages Disadvantages
Competitive element can Difficult to pitch the
be useful in increasing a exercises at a level suitable
person’s performance for all group members
A variety of exercises Temptation to put
is possible inappropriate individuals
in the group to save time
and relieve overburdened
staff

Group exercise can be fun Difficult to monitor all of

if properly organised the people all of the time

Helps the individual to feel Difficult to progress all the

less isolated if meeting members of the group
people with similar appropriately
problems

Provides a good Competitive element may

opportunity for the be counterproductive or
physiotherapist to educate dangerous
and inform the group
about the condition

Specialist groups such as Some people do not

ankylosing spondylitis or respond well in a group
cardiac rehabilitation situation
groups provide social
support
Figure 13.29  Group exercises in a pilates class.

298

Format of a group session
The format of a group session should include:
• patient assessment for suitability for group exercise
(at an individual appointment);
• a warm-up session;
• a main exercise session;
• a cool-down period.
A warm-up is commonly used to start a session to
improve circulation and increase body tissue temperature,
therefore physically, as well as mentally, preparing the
participants for exercise. Warm-up exercise may also limit
the build-up of metabolites and subsequent acidosis
during intense exercise (Kato et al. 2000). It is also inter-
esting to note that proprioception has been found to be
significantly more sensitive after warm-up (Bartlett and
Warren 2002).
Following the warm-up come the main exercises. It is
also important to allow time for a cooling-down, particu-
larly following vigorous exercise, to assist with removal of
lactic acid and waste products of metabolism.
Circuit training
Circuit training is often used in group work. Circuit train-
ing involves an exercise programme in which exercises are
performed in successive stations with either a predeter-
mined number of repetitions or for a set duration. Timed
rest follows each exercise period prior to moving to the
next station.
The exercises forming the circuit could be chosen from
any of the aforementioned exercise types. The exercises
included as part of the circuit must each form part of the
client’s overall rehabilitation goals. There will also usually
be a cardiovascular element to circuit training and it is
commonly used for cardiac or pulmonary rehabilitation
programmes.
The order of exercises in a circuit needs to be planned
from a safety aspect so that group members do not endan-
ger each other. Exercises also need to be ordered to achieve
optimum effectiveness. For example two exercises targeted
to achieve similar effects should not be placed adjacently
on a circuit as that might cause excessive fatigue of the
muscle groups involved unless this is the desired effect.
Key point
During group work the physiotherapist facilitates the
session by giving feedback and motivation to all
participants to ensure that they benefit fully from the
session. It is also important that the participants have a
home exercise programme to ensure their progress is
continued at home.
Exercise in rehabilitation Chapter 13
HYDROTHERAPY
Hydrotherapy involves exercising in water. The same prin-
ciples of exercising on dry land discussed in this chapter
are generally true when exercising in water. It is normal to
have clients performing individually-devised exercises
concurrently under supervision to gain the advantages of
group activity and maximal use of this often expensive
resource without the drawbacks of a class setting. However,
this still requires careful planning.
Hydrotherapy is used in the treatment of a wide
range of conditions to enhance cardiovascular fitness, to
mobilise, to strengthen, to co-ordinate movement and to
regain function of the neuro-musculoskeletal system.
Many hospital departments have purpose-built heated
hydrotherapy pools. The warm environment may allow
the muscles to work more effectively owing to a rise in
temperature and of the relaxation of any muscle spasm. It
will also have a pain-relieving effect. Conditions com-
monly managed by hydrotherapy are wide ranging, from
rheumatological conditions such as rheumatoid arthritis
and ankylosing spondylitis to trauma cases and neuro-
logical conditions.
Contraindications and precautions are important when
considering patients for any exercise programme and more
so with hydrotherapy owing to potential emergency
evacuation situations. This is mainly because of the warm
environment in which they are exercising and the dangers
of slipping or drowning. Contraindications include the
presence of certain medical conditions such as recent, or
severe, neurological conditions (including uncontrolled
epilepsy), certain cardiovascular problems and kidney
failure. Hydrotherapy is also contraindicated with debili-
tating disease and the presence of infections which may
be exacerbated or risk transmission to other patients.
The starting positions used to exercise in the pool will
be different from those commonly used on dry land.
Patients commonly exercise in standing or sitting in the
pool or perform more dynamic exercises such as walking
or swimming, but they can also be treated while floated
in lying. Floats are placed around the neck and waist to
support the patient, allowing the patient to exercise freely.
Floats may also be placed around the limbs.
The factors that need to be considered, other than start-
ing position, that change the nature of the exercise are
those of buoyancy, turbulence and streamlining.
Buoyancy
This results from the relative density of the body, or body
part, and the higher density of water. Buoyancy results in
an apparent loss of weight of the object when placed in
the water and it may be used to either assist or resist
movement. Buoyancy will be of particular advantage in
299
 Tidy’s physiotherapy
reducing the effect of gravity on the body, particularly on
load-bearing joints such as lower back, hips and knees.
Buoyancy may increase the function or the range of move-
ment that is possible, for example hip and knee flexion in
standing. It may also be utilised to increase range of move-
ment as a mobilising exercise, an effect that can be further
enhanced by the use of a float or inflatable wrist or ankle
bands, for example to mobilise shoulder flexion with a
wrist float in sitting.
Buoyancy can also be used in strengthening exercises.
Buoyancy-resisted exercise involves pushing against buoy-
ancy. The effect can be increased by again adding floats,
for example hip extension while floated in supine against
an ankle float.
Key point
The greater the buoyancy of the float the greater the
mobilising effect of the exercise. These types of exercise
are classed as buoyancy-assisted.
As the exercises are progressed, the inflatable bands can
be further inflated or, alternatively, the position of the float
on the lever can be adapted therefore changing the buoy-
ancy effect on the limb, i.e. the effect will be increased with
a distal float placement. If buoyancy is to be counterbal-
anced the patient will need to exercise along the pool
surface.
Turbulence
As limbs move through water they meet resistance and
turbulence is created, resulting in the production of cur-
rents. Turbulence results in an area of low pressure behind
the moving body or body part. Faster movements will
produce more turbulence. These currents may act to make
movement more difficult and so this principle is of value
when progressing an exercise, for example if exercises are
performed rapidly more turbulence will be created and
will prove more difficult to move though. Also, therapist-
created turbulence can be used in re-education of move-
ment, particularly in the weight-bearing muscles of the
lower limb. The client is subjected to turbulence during
standing and must maintain their position. This can prove
very difficult and can be quite an advanced exercise.
Streamlining
This refers to the surface area of the body part exposed to
the water when moving through it. The simplest example
is the orientation of the upper limb during exercise. If the
hand moves with the palm facing the resistance of the
water more effort is required than when the limb is rotated
300
Further study
For information on specific treatment techniques such as
Bad Ragaz and Halliwick, further reading or study is
required.
so that the ulnar border leads. Moving from streamlined
to non-streamlined positions can be used to progressively
strengthen. This principle can be further progressed by the
use of hand-held bats or by placing flippers on the feet.
EXERCISE PRESCRIPTION AND
COMPLIANCE
In this chapter we have considered many types of exercise
for varying populations and conditions. For prescription
of exercise to be effective as a treatment modality, selection
of the programme needs to be appropriate, as does how
the exercises are delivered. The way in which exercises are
taught will enhance their effectiveness by promoting com-
pliance and accurate performance.
It is good practice when teaching exercise, as with any
treatment intervention, to gain informed consent. Not
only does this conform to legal requirements but also it
serves to educate the patient on their condition presenting
a rationale behind the treatment approach. Education can
only enhance compliance with the exercises (Lee and Yoo
2004), as can active encouragement (Prasad and Cerny
2002). When teaching the exercises it may help to dem-
onstrate to the patient the intended exercise before giving
detailed instruction and feedback on performance. There
is no point in allowing an exercise to be performed incor-
rectly as it will not effectively achieve its intended goal. It
may benefit the patient to be given a clear, written copy of
their exercises, using lay terms; however, this should be a
personalised exercise programme. All too often patients
are given pre-printed sheets with little thought to indi-
vidual requirements. Written instructions should also
include information on how to perform the exercise, for
example speed, the number of repetitions, sets and dura-
tion of recovery, and also frequency (how many times a
day). It is important for the therapist to closely observe
the performance of exercise to detect for signs of substitu-
tion or fatigue. Substitution strategies may present with
movement dysfunction and it is necessary to inhibit over-
active muscles to correct abnormal recruitment patterns so
as not to reinforce dysfunction. Fatigue will also affect
performance so once early signs of fatigue are noted, it is
best to allow the muscles to rest and recover prior to per-
forming further sets.
Feedback is necessary, but should be given in a way that
does not reduce the effectiveness of your treatment causing
 Exercise in rehabilitation Chapter 13

demotivation. Feedback should also be used positively

to reinforce good performance. A positive outlook, high
quality education and constructive feedback will all serve
to improve motivation and, in turn, a patient that is highly
motivated will be more likely to comply with their exercise
programme.
As a final point it is also good practice to give a patient
a home exercise programme, to review it on each consulta-
tion and progress it as the patient’s improvement allows.
This will give good returns in rehabilitation rates as the
patient can actively participate regularly in the recovery
and maintenance of their condition.
Key point
For exercise to be successful ensure:
• that patients have clear instructions;
• that patients receive feedback on performance;
• that patients have been educated on the reasons
behind their exercise;
• to give regular constructive feedback and
encouragement.

ACKNOWLEDGEMENTS

With thanks to Sean Kilmurray, University of Central Lancashire, for his original contribution and Paul Cieplak (MSc
advancing physiotherapy student, University of Salford) and Sante Saleh (BSc Honours physiotherapy student, University
of Salford).

FURTHER READING

Crook, P., Stott, R., Rose, M., et al.,
1998. Adherence to group exercise:
physiotherapist-led experimental
programmes. Physiotherapy 84,
366–372.
Jerosch, J., Prymka, M., 1996.
Proprioception and joint stability.
Knee Surg Sports Traum Arthrosc 4,
171–179.
Kisner, C., Colby, L.A., 1996.
Therapeutic Exercise:
Foundations and Techniques,
third ed. FA Davies,
Philadelphia.
Lieber, R.L., 1992. Skeletal Muscle
Structure and Function:
Implications for Rehabilitation and
Sports Medicine. Williams &
Wilkins, Baltimore.
Mense, S., Simons, D.G., Russell, J.
(Eds.), 2001. Muscle Pain:
Understanding its Nature, Diagnosis
and Treatment. Lippincott Williams
& Wilkins, Philadelphia.
Richardson, C., Hodges, P.W., Hides, J.,
2004. Therapeutic Exercise for
Lumbopelvic Stabilization. A Motor
Control Approach for the Treatment
and Prevention of Low Back Pain,
second ed. Churchill Livingstone,
London.
Richie, D.H., 2001. Functional
instability of the ankle
and the role of neuromuscular
control: a comprehensive
review. J Foot Ankle Surg 40,
240–251.
Tippet, S.R., Voight, M.L., 1995.
Functional Testing in Functional
Progressions for Sport
Rehabilitation. Human Kinetics,
Champaign, IL.

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303
 Chapter
Muscle imbalance
Alan Chamberlain, Wendy Munro and Alec Rickard
INTRODUCTION
The concept of muscle imbalance (and balance) is not
new. This is evidenced through over 60 years of texts
involving muscle testing and function (Kendall et al.
2005) and has evolved over the most recent of those years
through work from the likes of Janda (1983), Sahrmann
(1987), Richardson (1992), Jull et al. (1999) and others.
Clearly, alterations in muscle balance cannot be consid-
ered in isolation, but must be considered as part of move-
ment control, where the differentiation of the factors
leading to movement dysfunction is essential and part of
the holistic assessment and management of individuals
with musculoskeletal pain.
This chapter concentrates on the adaptation of muscle
in relation to posture and movement patterns, and the
relationship to musculoskeletal pain syndromes. The fol-
lowing knowledge and understanding of the reader will be
assumed:
• the micro- and macro-anatomical structure and
physiology of muscle and associated tissue;
• micro- and macrostructure related to function;
• macro-anatomy or gross anatomy of muscles and
muscle groups, along with their relationships to each
other and other tissue structures, such as bones,
joints, connective tissue, viscera, neural and vascular
tissue; in other words, what lies deep, superficial,
superior, inferior, medial and lateral to the structure
being considered.
In order to contain this subject within the limits of a
manageable chapter, only the more commonly affected –
and/or those deemed clinically important – muscle groups
will be discussed, utilising select key clinical examples.
However, the principles described in this chapter should
be transferrable to any region in the body. In addition,
when considering cause, effect and recovery, the Specific
14 
Adaptation to Imposed Demand (SAID) principle should
be applied, as originally proposed by Selye (1951).
Example case scenarios will be illustrated using the sub­
jective, objective, analysis, plan and evaluation (SOAPE)
process, familiar to physiotherapists from a plethora of
texts and institutions (Baxter 2003).
Clinical note
The assessment of muscle imbalance and management
of musculoskeletal disorders with muscle balance
techniques is just one approach amongst the plethora of
physiotherapeutic assessment and management skills. It
can be described as a method to rehabilitate patients
presenting with movement dysfunction and its associated
problems. Analysis of the subjective and objective
assessment of the patient is key to identifying this as
an appropriate modality for rehabilitation through
hypothesis testing, clinical and critical reasoning, and
evaluation of practice.
What is muscle imbalance?
As physiotherapists, we need to be able to differentiate
between what is considered a ‘normal’ (or ‘expected’)
range of motion (ROM) and that which is deemed ‘abnor-
mal’ – either hypo- or hypermobility – along with which
structures may produce or restrict the range of motion.
It must be noted that there may also be an underlying
predisposition – or pathology – for hypo-/hypermobility,
as in the case of connective tissue conditions, such as
ankylosing spondylitis and hypermobility syndrome (see
Figure 14.1) (as distinct from a joint demonstrating
hypermobility), or neurological conditions, such as mul-
tiple sclerosis. However, it is outwith the scope of this
chapter to discuss these specific pathological causes.
305
 Tidy’s physiotherapy
A These descriptions are all well and good, but, unfor­
B
Figure 14.1  (a, b) Classical hypermobility syndrome.
Definition
Richardson (1992) described muscle imbalance as a
specific problem of movement dysfunction, concerned
with inadequate control and co-ordination of muscles for
the protection of joints and surrounding structures.
Muscle imbalance can be either ‘passive’ or ‘active’;
passive being identified by muscle length and strength
being either less or more than the ideal, and active being
identified when one of a synergistic pair of muscles pre-
dominates during the movement (Sahrmann 1987). The
resultant functional and structural changes in the muscle
appear to be reversible, suggesting that exercise to facilitate
muscle length changes will be useful in the management
of movement dysfunction (Gossman et al. 1982).
Perhaps it is worth reviewing the general characteristics,
function and roles of muscles first. Muscles can act as
prime movers, or agonists, if they are primarily responsible
for producing movement. Their direct opposites are antag-
onists, which do not normally oppose movement, but have
306
the potential to do so if they are not inhibited; for example,
when flexing the elbow, biceps brachii is the agonist whilst
the triceps is the antagonist (relaxed, via reciprocal inhibi-
tion). Co-contraction of muscles is possible, which can
assist movement and/or stabilise. When this occurs to
assist the movement produced by the agonist, those
muscles are said to be working as synergists (see the
example of the scapular force couple in the shoulder
section). When muscles contract to stabilise a joint and
control the position of the origin of an agonist, they are
known as fixators (or stabilisers, i.e. in the case of elbow
flexion as above, the fixators would be those that stabilise,
or fixate, the shoulder, such as the rotator cuff).
tunately, prove rather inadequate when it comes to ex­­
plaining more dynamic, complex movements. Therefore,
further classification of the role of muscles has been
attempted by various authors according to their anatomy,
architecture, fibre type and function, as summarised in
Table 14.1. To simplify, some muscles exhibit a tendency
to be more stabilising (i.e. multifidius in the spine) or
mobilising in their function (i.e. erector spinae), although
there are also some that demonstrate characteristics of
both and can ‘multitask’ their role depending on the
demands placed upon them at the time. Examples of the
latter include the vasti muscles of the quadriceps and
soleus. Throughout this chapter, muscles will be discussed
in relation to their functional role as local and global
stabilisers, or global mobilisers.
Problems may occur when, for example, a predomi-
nantly stabilising muscle is injured or dysfunctional,
leading to instability and altered joint biomechanics,
increased strain on structures, such as joint surfaces, and
pain. Muscles with a predominantly mobilising role can
be used as temporary stabilisers, but as their anatomy and
physiology does not lend themselves to this, this may lead
to overuse, fatigue and pain. It has been suggested that
myofascial trigger points (taut, irritable bands within
muscles resulting from overuse) may develop as a result
(Simons et al. 1999; Fernández-de-las-Peñas et al. 2006)
and which can perpetuate the muscle imbalance through
further pain and resultant inhibition.
Therefore, in short, if muscle imbalance is present and
the muscles are unable to fulfil their role correctly, this can
be through either being unable to stabilise or induce/
permit movement because one or more are either too
weakened and/or lengthened, or too over-active and/or
shortened.
Stability
Additionally, the term ‘stability’, particularly ‘core stability’,
has also become synonymous with approaches to dealing
with muscle imbalance of the spine, especially in the
lumbar spine. Confusion can arise with this term, par­
ticularly when used very specifically by one group of
 Muscle imbalance Chapter 14

Table 14.1  Summary of the different classifications of muscle roles

Janda (1994), Jull Bergmark (1989) Richardson (1992) Comerford and

and Janda (1987) Mottram (2001)

Phasic Local muscles Stability synergists Local stabilisers

Tend to lengthen Deepest muscle layer that
Weak originates and inserts
Uni-articular segmentally
Control and maintain
neutral
Respond to changes in
posture and to changes in
low extrinsic load
Independent of the
direction of load or
movement and appear to
be biased for low load
activity
Single joint muscle
Aligned to oppose gravity
Approximates the joint
Deep
Extensive aponeuroses
Slow twitch (type I) muscle
fibres
Control low force levels for
long periods
Increased muscle stiffness
to control segmental
motion
Controls the neutral joint
position
Contraction = no or
minimal length change so
does not produce
movement
Activity is independent of
direction of movement
Continuous activity
throughout movement
Proprioceptive input through
joint position, range and
rate of movement

Postural Global muscles Mobility synergists Global stabiliser

Tend to tighten Superficial or outer layer of Fast twitch muscle fibres Generates force to control
Bi-articular muscles lacking (type II) range of motion
One-third stronger segmental vertebral Suited to production of high Contraction = eccentric
Trigger points insertions speed movement length change – control
Lower irritability Insert or originate on the Span two joints throughout range
threshold thorax or pelvis Subject to high force values especially inner range
Respond to changes in the and outer range
line of action and the Low load deceleration of
magnitude of high momentum (especially
extrinsic load axial plane:rotation)
Large torque producing Activity is direction
muscles biased for range dependent
of movement

Global mobilisers

Generates torque to
produce range of motion
Contraction = concentric
length change –
concentric production of
movement
Concentric acceleration of
movement (especially
sagittal plane:flexion/
extension)
Shock absorption of load
Activity is direction
dependent
Non-continuous activity
(on:off phasic pattern)

Adapted from Comerford and Mottram (2001) and Norris (1995).

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 Tidy’s physiotherapy

Load

ROM

Flexion

NZ

Control
subsystem
Displacement

Extension

Passive Active ROM

subsystem subsystem
Figure 14.2  A model of stability. Adapted from Panjabi (2003).
NZ

professionals to be more than merely a descriptive state;

when is someone or something stable or unstable,
what makes someone or something stable/unstable? For
example, an orthopaedic surgeon may well be focussing
on the bony congruency or ligamentous support at a
spinal segment and any trauma or pathology associated
with this (as in spondylolithesis) as the cause of instabil- ROM
ity. Conversely, a physiotherapist, unless assessment sug-
NZ
gests otherwise, may be concerned with the quality of the
spinal movement, any associated/compensatory move-
ments and the support of the muscles to stabilise the
movement. Therefore, the stability of the spine, in this
example, is dependent on a number of factors. Figure 14.2 B
demonstrates a basic model of stability that considers
the interplay of the principal systems involved (Panjabi Figure 14.3  Load–displacement curve. (a) The effect of
flexion and extension loads on a spinal segment, exhibiting
1992a, 1992b, 2003).
a nonlinear load displacement curve. The neutral zone (NZ)
Panjabi (1992a, 1992b, 2003) additionally discusses parameters represent laxity of the spinal segment around
control of the neutral zone: the area (or zone) around the the neutral position. (b) A graphic analogue of the load-
segment’s neutral position where there is little resistance displacement curve where the extension curve from (a) is
offered by the passive restraints in response to a small just inverted. A deep champagne glass and a shallow bowl
range of displacement (see Figure 14.3). Although origi- represent a more and a less stable spine respectively, as the
nally related to the spine, this model can be applied champagne glass has a smaller NZ, greater load (in this case,
equally to the appendicular, as well as the axial skeleton, titling the glass) is required to cause the ball to displace/
when considering the interplay of the subsystems. This move. Reproduced from Panjabi (2003), with permission.
control of the neutral zone can be disturbed locally by the
dysfunction of recruitment and motor control of the
deep segmental stabilisers, and globally by an imbalance
between the mono-articular stabilising muscles and the
bi-articular mobilising muscles (Comerford and Mottram
2001). It is hypothesised that an increase in the size of the

308

neutral zone (therefore decreased ‘stability’ or increased
‘instability’, if you like) correlates with pain and dysfunc-
tion (and possibly could be caused by either); correspond-
ingly, decreasing the neutral zone may decrease pain and
dysfunction (Panjabi 2003). However, it must be noted
that the clinical reality is rarely this straightforward and is
usually multifactorial (see Chapter 17)!
NEUROPHYSIOLOGICAL
COMPONENTS OF MUSCLE BALANCE
To understand the concept of muscle imbalance and the
implications of the alteration in muscle function, the neu-
rophysiological components of muscle balance will be
discussed first.
Motor control
Stabilisation requires automatic recruitment of the muscles
surrounding the joint. This requires appropriate co-­
activation of muscles, the application of appropriate levels
of force for the task in hand and appropriate timing of the
muscles (Richardson 1992). Normally, the mono-articular
stabilisers should activate earlier than the multi-articular
mobiliser synergists – a feed-forward mechanism. This
co-ordinated activity involves sensory strategies through
feedback from the joint and ligament afferents, and muscle
spindle activity, along with biomechanical, motor process-
ing strategies and learned behaviour that anticipates
change (Comerford and Mottram 2001).
Motor units (the motor neurone and the muscle fibres
it innervates) contain the same type of fibre so that there
are, pragmatically, two main types: slow (tonic, type I
fibres) motor units and fast (phasic, type II fibres) motor
units. Therefore, slow motor units have a slow speed of
contraction, low contraction force and are fatigue resist-
ant compared with fast motor units. Slow motor units
are recruited primarily at low loads of less than 25%
of maximum voluntary contraction (MVC) and fast
motor units are recruited at higher loads (Gibbons and
Comerford 2001). Therefore, the recruitment of slow
motor units, and use of muscles with high proportions of
these is necessary for optimal stabilisation. When mobi-
liser muscles, which contain high proportions of fast
motor units are utilised as compensation for stabiliser
dysfunction, degradation of the fine control results along
with fatigue and potentially pain and spasm if then
over-used.
However, biased recruitment of shortened muscles can
be a problem. It is suggested that short muscles are
recruited more easily than their lengthened synergists
(Sahrmann 1987). This may be owing, mechanically,
to the increased overlap of actin and myosin (as in the
sliding filament theory, below) leading to an increase in
the intrinsic ‘stiffness’ of the muscle and readiness for
Muscle imbalance Chapter 14
activation, and owing, neurologically, to the increased
excit­ability of the alpha motor neurone pool facilitated by
the increased tension and activity of the muscle spindle
afferents (Comerford and Mottram 2001).
There is evidence to suggest that the reduction of pro-
prioceptive input during sustained low-load contractions
from the muscle spindle changes the recruitment order
of the motor neurones and the normal dominance of
the local stabilisers (Grimby and Hannerz 1976, cited in
Comerford and Mottram 2001). Janda (as discussed
by Comerford and Mottram (2001)), identified and quan-
tified recruitment and sequencing differences between
synergistic muscle groups in functional movement. From
this, he was able to identify a consistent recruitment
pattern in asymptomatic individuals and also charac­
teristic abnormal patterns in symptomatic individuals.
Similar evidence has been identified by several authors in
relation to individuals with impingement symptoms of
the shoulder (Ludewig and Cook 2000; Cools et  al.
2003), cervicogenic headaches (Jull et  al. 1999) or patel-
lofemoral pain (McConnell 1996).
Muscle length adaptations
Several theories exist relating to the relationship between
muscle length and strength (Sahrmann 1987), and are
listed below.
Stretch weakness
It is suggested that stretch weakness occurs when a muscle
is maintained in an elongated position beyond its neutral
physiological rest position but not beyond the normal
range of muscle length (Gossman et al. 1982). Examples
of this may be weakness of the dorsiflexors in a bedridden
patient when held in a lengthened position owing to the
weight of the bed clothes holding the foot in a plantar
flexed position. Equally, prolonged postural strain, such as
drooping shoulders with elongation of the middle and
lower trapezii, can lead to stretch weakness.
Positional weakness and length
associated changes
When a muscle is immobilised in a lengthened or short-
ened position, the muscle adapts in order to either increase
or decrease the number of sarcomeres respectively. This
change in number allows for a change in sarcomere length
to one that gives maximum overlap of actin and myosin
for optimum cross bridge formation and the ability of the
muscle to achieve maximum tension in the immobilised
position (Williams and Goldspink 1978). These adapta-
tions appear to differ with age, occurring primarily in the
tendon in young people rather than muscle (Gossman
et al. 1982), such that immobilisation in a lengthened
309
 Tidy’s physiotherapy
100
Tension (percent of maximum)
80
60
40
20
0
1.2µm 2.1µm
Decreased length
Optimal resting length
Figure 14.4  The sliding filament theory and length tension curve.
position leads to elongated tendon and shorter muscle
belly with a reduction in the number of sarcomeres in the
muscle belly.
Clinical note
Clinical implications of these adaptations are that
muscles will test stronger in their ‘new’ position, but will
test weaker in their normal physiological resting position.
It has been shown that once immobilisation of a muscle
in an altered position is discontinued, the muscles should
regain their ‘normal’ sarcomere number and length
(Tabary et al. 1972).
Williams and Goldspink (1984) also demonstrated
changes in the connective tissue of the muscle when a
muscle was immobilised in a shortened position. It is
generally thought that muscle has a parallel elastic com-
ponent (primarily from the perimyseum, but also the
epimyseum) to the active contractile element. This parallel
elastic component is thought to distribute forces associ-
ated with the passive stretch of the muscle and maintain
the relative position of the fibres. In a muscle immobilised
in a shortened position the increase in connective tissue
is likely to result in an increase in muscle stiffness and
reduced elasticity of the muscle.
Similar changes may occur when a muscle works at a
shorter length (Williams and Goldspink 1984) and it
should be noted that normal, transient changes in muscle
length, as part of movement and positioning, will affect
310
2.2µm 3.6µm
Increased length
the tension that can be developed, as demonstrated by the
sliding filament theory and the muscle length tension
curve (Figure 14.4).
In addition, where a muscle is bi-/multi-articulate, then
active and passive insufficiency can occur. Active insuffi-
ciency is the inability of a bi-/multi-articulate muscle to
generate enough tension in a shortened position, where
the position of one joint affects the tension of the muscle
at the other. A classic example is the hamstrings: if you
stand with your knees extended and your hips flexed (i.e.
in a bow), the hamstrings are able to extend your hips/
pelvis to raise your body upright, but if you do the same
starting with your knees flexed, your hamstrings are disad-
vantaged and you rely on your gluteus maximus. The same
occurs with the finger flexors if you try to flex the fingers
to make a fist with your wrist fully flexed (although here
you also encounter passive insufficiency), whereby the
wrist extensors are fully lengthened across two or more
joints (the wrist, metacarpalpharangeal and interpharan-
geal joints).
Relative flexibility and  
relative stiffness
‘Relative stiffness’ as described by White and Sahrmann
(1994) in one segment will require flexibility in an adja-
cent area to gain functional movement. This relative stiff-
ness can occur as discussed above in a shortened muscle,
but also when the passive structures around the joint
(capsule and ligament) or the joint surfaces themselves
become restricted in their movement. An example of this

might be an adhesive capsulitis of the glenohumeral joint;
restriction of the capsule around the joint causes limita-
tion of abduction resulting in hypermobility of the
scapulo-thoracic joint to gain movement and hence
lengthening of the stabilising muscles of the scapula on
the chest wall. Similarly, ‘relative flexibility’ (White and
Sahrmann 1994) can occur where mono-articular muscles
are unable to adequately shorten, so are lengthened,
strained or weak and allow excessive motion at the joint
they act upon. This increase in mobility has obvious impli-
cations on initiating pathology. This relative stiffness and
flexibility gives rise to the concept of ‘give and restriction’,
as discussed by Comerford and Mottram (2001).
EXAMINATION AND ASSESSMENT
PRINCIPLES
The examination and assessment process is required to
determine whether muscle imbalance is a causal factor of
the patient’s symptoms. Recognition of postures that
deviate from the expected normal (see Kendall et al. 2005)
and of physiological movement dysfunction patterns (as
detailed in Table 14.2) is essential to this.
It is also necessary to identify whether the abnormal
postures and movement patterns are the primary or sec-
ondary source of the patient’s symptoms (see ‘Clinical
note’ in the cervical spine section below). Secondary
stresses can give rise to symptomatology in any part of the
kinetic chain affected by the alteration of posture and
physiological movement further along the chain. The signs
and symptoms of other anatomical regional areas will
need to be addressed, but causal primary problems must
always be recognised and addressed, as well as those that
have developed secondarily.
Treatment, intervention and
management principles
As well as the theory described in this chapter, it must be
noted that there are other factors to consider in order to
determine the most effective and efficient intervention,
such as psychosocial influences, age and comorbidities.
Consideration also needs to be given to the patient’s
expectations. Are the function and demands they expect
to place upon themselves compatible with attaining/
maintaining ‘muscle balance’?
The physiological parameters already discussed should
inform your treatment decisions. Table 14.3 provides an
overview of management principles.
In practice, there is an additional consideration and
experiential, anecdotal phenomenon, which is important
to consider for the life-busy (perceived or actual) patient
who is at risk of non-compliance of rehabilitation if the
Muscle imbalance Chapter 14
Table 14.2  Key assessment principles
Subjective examination
Check past medical history for pathological/contributory
causes of observed posture
Exclude red flags
Consider subjective history and how occupation/
functional activities relate to the observable posture
Prioritise objective assessment taking into account SIN
factor (severity/irritability/nature)
Objective examination
Postural assessment
Assess global posture – gauge what is their ‘normal’ and
what has contributed to, or resulted from, their
presenting problem
Check for neutral joint position in the joint(s) relevant to
the individual’s problem
Develop a hypothesis of weakened and/or lengthened
and overactive and/or shortened muscles
Observe physiological movement
Observe the quality and measure active/passive
physiological range of movement
• Differences owing to influence of soft tissues?
Assess end-feel
• Firm/springy = owing to soft tissue tightness?
• Empty = owing to hypermobility?
Note any symmetry/asymmetry and any deviations away
from the normal path of movement
Test muscle strength and length
Test weakened/lengthened muscles to see if they can
generate and maintain tension in their shortened
position
Test length of shortened muscles
Identify compensations
Substitution or dominance of the global stabiliser or
mobiliser muscles where there is dysfunction of the
local stabilisers
→ e.g. where the neutral position of the scapula
cannot be maintained on the chest wall there may
be substitution or dominance by the rhomboids,
levator scapula, pectoralis minor or latissimus dorsi
→ or where there is a weakness of transversus
abdominis producing an anterior tilted pelvis and a
secondary increased lumbar lordosis or vice versa
Where there are shortened muscles leading to
hypomobility, observe where the movement occurs to
achieve function. (e.g. individual with a shortened
hamstring when sitting and asked to extend the knee
may compensate by flexing the lumbar spine)
NB. Check you have fully assessed the available length
and strength. Could apparent restrictions or weakness
be a result of the testing position itself?
311
 Tidy’s physiotherapy

Table 14.3  Overview of management principles Table 14.4  The main lumbo-pelvic mobiliser and
stabiliser muscles
1. Isolated retraining
Recruitment of appropriate stabilisers Muscle Primary muscle role
Low/no load (may need facilitation, auto-assistance,
etc.) Transversus abdominis Local stabiliser
Low repetition
Concentrate on correct movement with no Multifidus Local stabiliser (deep
compensation intersegmental fibres)
2. Strengthening Global stabiliser
Low-load, low effort for stabilisers (superficial fibres)
→ 25% MVC Rectus abdominis Mobiliser
Increasing repetitions and/or load gradually whilst
maintaining correct movement External oblique Global stabiliser
→ endurance versus power Mobiliser
→ avoiding compensatory strategies, especially
recruitment of mobilisers Internal oblique Local stabiliser
3. Lengthening Mobiliser
Lengthen tight structures once ‘stabilised’ Erector spinae Mobiliser
Consider dynamic versus static
4. Education and advice (but may also be commenced
early on)
Avoid/minimise postures which lengthen weakened
structures
Avoid/minimise activities that facilitate dominant/
overactive muscles
Advise on alternative postures/activities
→ Consider appropriate equipment/aids, i.e. seating,
lumbar roll, etc.
Ribs
Diaphragm
programme is too time-consuming. Well-intended pro-
grammes have been known to be overloaded and discon-
tinued if it becomes too much and so it may be prudent
to withhold some lower priority rehabilitation for a later
date and introduce as proven necessary.
Transversus
Multifidus
abdominis
The Lumbo-pelvic region
The lumbo-pelvic region has seen a significant amount of
research and debate as to the role of the muscles in rela-
tion to lower back pain, which should not be surprising Pelvis
considering how common lower back pain is. However, it Pelvic floor
remains a complicated area and so it is beyond the scope
of this chapter to consider all muscles and potential per-
mutations of imbalance. As transversus abdominis (TrA)
Figure 14.5  The ‘core’ stabilisers.
has received considerable interest both in the literature
and clinical environment, this will be the focus as a tem-
plate approach for the physiotherapist to consider in rib cage) and pelvis (see Figure 14.5). Therefore, whilst the
practice. Table 14.4 lists the main muscles acting on the lumbar vertebrae and intervertebral discs are the largest
lumbo-pelvis with their respective primary functional role. and strongest in the spine, further support and control is
The concept of ‘core stability’ and muscular stabilisation required, but, as you will see in Figure 14.5, TrA, along
of the lumbar spine has derived from Panjabi’s (1992a, with the multifidus, diaphragm and pelvic floor, appear to
1992b, 2003) model of the three subsystems described form a ‘box’ (or more aptly, a corset). The diaphragm and
previously. With reference to the passive subsystem, the pelvic floor appear to contribute mainly through increas-
lumbar spine appears to be at a disadvantage, ‘sandwiched’ ing intra-abdominal pressure and restricting the move-
between the inherently more stable thoracic spine (via the ment of the viscera (Richardson et al. 2004).

312

Slowly draw in the lower abdominal wall
Front
Abdominal contents
External obliques (relaxed)
Internal obliques (relaxed)
Transversus abdominis (contract)
Back
Figure 14.6  Transversus abdominis and multifidus.
Transversus abdominis (TrA)
TrA is the deepest of the abdominal muscles (Figure 14.6).
The direction of the muscle fibres runs horizontally medi-
ally from the lateral attachments of the internal surface
of the six lowest ribs, the thoracolumbar fascia, internal
surface of the iliac crest and the lateral third of the inguinal
ligament to the sheath of rectus abdominis (Ombregt
et al. 2003; Standring 2005). It can be seen from the
attachments how contraction can mechanically increase
intra-abdominal pressure and thus stabilise the lumbar
spine, although it does not act alone, as co-contraction
with multifidus is also thought to occur (Richardson et al.
2002, 2004). When considering this action, it is easy to
understand how dysfunction may lead to pathological
signs and symptoms, and subjects with low back pain
have been shown to demonstrate delay and inhibition
of contraction compared with asymptomatic subjects
(Richardson et al. 2002, 2004).
It is widely accepted that TrA provides support for the
abdominal contents and it has been demonstrated through
research that it provides indirect stability for the lum-
bosacral spine and sacroiliac joints (Richardson et al.
2002, 2004). The associated levers of the pelvis and spine
arising from these joints must be remembered together,
with further consideration when relating TrA structure to
its function and the stabilising of the pelvic postero-
anterior lever in neutral; in other words, maintaining an
antero-posteriorly neutral pelvic level.
Muscle imbalance Chapter 14
Rectus abdominis (relaxed)
Spine
Multifidus (co-contract)
Most of the literature explains how the pelvis is stabi-
lised in the neutral position by the indirect stabilising role
on the lumbo-sacral and sacroiliac joints, but it can be
argued that the pelvis is stabilised in neutral on the spine
and prevented from anteriorly tilting directly anatomically
through the attachment to the pubis and indirectly via
rectus abdominis.
Mechanically, transversus abdominis may have a direct
role in maintaining pelvic neutral, producing a cephalic
force on the anterior pelvis owing to the lower fibres of
the muscle curving inferiorly and medially to attach to the
pubic crest and pectineal line, along with the aponeurosis
of internal oblique (Standring 2005). Further to this, if,
on contraction, it places tension on the rectus abdominis,
which in turn attaches to the costal cartilages and ribs
superiorly and pubis inferiorly, it can be mechanically
argued that transversus abdominis has an indirect role in
stabilising and maintaining the pelvis in neutral relative
to the spine. This, therefore, helps prevent anterior tilt of
the pelvis. An anterior tilted pelvis can therefore present
as a sign of transversus abdominis weakness and, from
clinical experience, has been supported or accompanied
by poor palpable contraction of the muscle. The same
anterior tilted pelvis may be the causal link for increasing
the lumbar lordosis and therefore be a source for causing
mechanical back pain, for example through increased facet
joint irritation from the resultant increased compression
force production.
313
 Tidy’s physiotherapy
It is not only weakness that can lead to an anterior tilted
pelvis. The lower fibres of TrA and all the fibres of rectus
abdominis may adaptively lengthen over time, such as
during pregnancy in women, for example. Also, through
prolonged, repeated and sustained static posture in sitting
there can be an over-compensatory posture with an ante-
rior tilted pelvis and hyper-lordosis of the lumbar spine in
an attempt to maintain a normal lumbar lordosis. This
would be considered to be the adverse effects of the SAID
principle (Selye 1951). In other words, unwanted adapta-
tion to adverse imposed demand, such as lengthening of
the abdominal muscle fibres and the anterior longitudinal
ligament of the spine.
In the case of the former example, intervention would
require, following confirmation through examination and
analysis, recovery of the optimal length, contractibility and
strength of the TrA muscle fibres; however, in the case of
the latter, it would also require prevention in recurrence
through changing postural habits. It has to be borne in
mind that the above presentation may be asymptomatic
initially and what transpires can be any other number of
signs and symptoms of other secondary or tertiary prob-
lems, such as ‘knock-on’ cervico-thoracic or shoulder
problems, but it is beyond the scope of this chapter to list
or discuss all the potential problems that can arise from
an anterior tilted pelvis through muscle imbalance.
Before considering further theory and research, the
physiotherapist must also understand that it has also been
argued in the literature (Richardson et al. 2002, 2004) that
TrA can become non-functional as an inhibitory response
Table 14.5  Other contributors to the development of an anterior tilted pelvis and additional associated/
secondary problems
Muscle Problem
Iliopsoas Too short/passive insufficiency causing
anterior tilted pelvis
Quadratus Too short/passive insufficiency causing
lumborum an increased lumbar lordosis and
an anterior tilted pelvis
Multifidus Weakness/lengthening or over-
activity/shortening
NB: It should also be noted that muscles involving the lower limb, which also act on the pelvis need consideration, such
as rectus femoris and the hamstrings (see Kendall et al. (2005) and others regarding postures such as the pelvic-crossed
syndrome).
314
to problems, such as mechanical low back pain. It is con-
sidered here that this may not be the order of events in all
mechanical low back pain and it is difficult to research the
order of events, as it would be necessary to have otherwise
healthy subjects induce mechanical low back pain in order
to determine if this is the point TrA switches off. Neverthe-
less, the physiotherapist can only treat what presents and
in the presence of a non-functioning TrA the challenge is
to rehabilitate the muscle.
As described above, the SOAPE process will be used for
further illustration.
Subjective examination
The subjective reporting of pain may be evident and may
be region specific over the lumbar spine with possible
radiation into the glutei and lower limb, unilaterally or
bilaterally.
Symptomology may occur in secondary areas both prox-
imally and distally affecting the thoracic and cervical spine
and upper and lower quadrants owing to the altered align-
ment of the lumbar spine posture and its knock-on effect
on posture elsewhere. Signs and symptoms will need to
be addressed but, equally, the other causations of an ante-
riorly tilted pelvis or associated and secondary lumbo-
pelvic-hip complex problems would need investigating
and correcting as necessary (see some examples in the
non-exhaustive list in Table 14.5).
Other subjective history may include continence prob-
lems if the pelvic floor muscles are weak in addition to
Additional associated/secondary problems
Increased lumbar lordosis and lumbar spinal dysfunctional
restriction of lumbar flexion range of movement (ROM)
Hip lateral rotational dysfunctional restriction of ROM, and
shortening of internal rotators and adductors of the hip
Hip extension dysfunctional restriction of ROM
Shortening of other hip flexor, rectus femoris
Shortening of other muscles of quadriceps femoris
Medial knee joint stresses
All of the above
Plus, unilateral imbalance may cause rotation/torsion or
lateral pelvic tilt
Although acknowledged as segmental stabilisers,
collectively they can contribute to the maintenance of
abnormal posture if dysfunctional, such as hyperlordosis
and therefore predispose to anterior tilt

TrA owing to their proximity and potential involvement
in lumbo-pelvic stability (see Figure 14.5). Specific correct-
ing postures may be recognised as relieving factors of sub-
jective pain, such as lumbar flexion. If neural structures are
irritated owing to narrowing of the intravertebral foramina,
paraesthesia, anaesthesia and pain radiating in the der-
matomal distribution may be complained of.
Objective examination
On observation
In standing: Lateral view
Anterior tilted pelvis may be seen. Other observations may
also include some or all of the following superiorly:
increased lumbar lordosis; increased thoracic kyphosis;
protracted cervical spine; protracted shoulder girdle. An
increased lumbar lordosis and/or an anterior tilted pelvis
may be less visible to the observer if the former is masked
by protective lumbar paravertebral muscle spasm and the
latter by adipose tissue. The latter may equally be coupled
with a clear observation of a low toned abdominal wall.
Measurements
It is possible to compare the levels of the anterior superior
iliac spine (ASIS) and posterior superior iliac spine (PSIS)
by palpating them simultaneously, but achieving an angle
measurement with a goniometer using these two bony
points is either difficult (reducing validity and reliability)
or not possible for all somatotypes. There can be a normal
slight anterior tilted pelvis, but it is whether it is excessive
or not and whether it is a result of weakness of TrA that is
important.
High criterion-validity using a universal goniometer has
been demonstrated when measuring knee joint move-
ment, but there is sufficient evidence to ensure content
validity using this method to measure range of movement
(Clarkson 2000). Joint range of movement (ROM) can
be reliably measured using a universal goniometer when
the same physiotherapist uses the same measurement tool
and a standard test position and protocol (Clarkson and
Gilewich 1989, cited in Walsh et al. 1998; Clarkson 2000).
If there is intra-tester reliability and validity for joint ROM
measurement, the same can only be assumed in the meas-
urement of other ROM. Accepting universal goniometer
validity and reliability in practice, one of us developed a
measurement technique that involves identifying the
tangent of the normal iliac crest (line AB, Figure 14.7) and
the ASIS (point d). With the fulcrum of the goniometer
being placed perpendicular to the tangent (point c), the
stationary arm of the universal goniometer is aligned with
line AB, maintaining it in the horizontal plane, and the
adjustable arm is aligned with point d. It sometimes
requires the operator to move the goniometer back and
forth posteriorly and anteriorly until the operator is satis-
fied the fulcrum is aligned with point c and the arms of
the goniometer are aligned with their respective points.
Muscle imbalance Chapter 14
A B
c
Anterior Posterior
d
Figure 14.7  Lateral view of normal pelvis.
A B
c
Anterior Posterior
d
Figure 14.8  Lateral view of a pre-test anterior tilted pelvis.
A B
c
Anterior Posterior
d2
d1
Figure 14.9  Lateral view of an anterior tilted pelvis during
the test.
It is accepted that the universal goniometer fulcrum is
usually aligned with the fulcrum of movement in periph-
eral joints and that the fulcrum of movement of the pelvis
does not occur at point c and, in reality, occurs at the
lumbo-sacral spine. However, provided the test position
and protocol is followed as described, it is reasonable to
use in clinical practice but it remains subject to validity
and reliability studies before it can be used in research. If
the pelvis is anteriorly tilted, the tangent of the iliac crest
would be equally tilted and it would therefore still require
the operant to align the stationary arm with a horizontal
line at the true apex of the iliac crest, which will be situated
inferiorly to the norm.
From experience in clinical practice, the normative angle
aĉd is 10°–20° depending on the size of the subject being
measured. An excessive angle beyond these values would
help confirm and quantify the observed and palpated
anterior tilted pelvis. It is this same angle that contributes
to monitoring progress of intervention and helps to form
one outcome measure in the presence of a weak or non-
functioning TrA (Figures 14.8 and 14.9). Using intentional
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 Tidy’s physiotherapy
cognitive contraction of the pelvic floor muscles is consid-
ered to be one of the most effective methods of achieving
isolation of contraction of TrA (Richardson et al. 2004). It
is supported from clinical practice experience and provides
additional palpable and measurable feedback. If the physi-
otherapist palpates the lower abdomen just superior to the
mid-point of the inguinal ligament, prior to measuring
movement, and asks the subject being examined to con-
tract the muscles that would prevent opening the bowels
and/or flow of urine, this should help the understanding
of contracting the pelvic floor alone and prevent contrac-
tion and mobilisation of the pelvis by the other abdomi-
nal muscles. If the action of TrA is closely linked to that
of the diaphragm and pelvic floor (Richardson et al.
2004), it seems reasonable to consider contracting what is
hopefully a stronger muscle group in the subject in order
to synergically elicit a contraction in the weaker or non-
functioning muscle. Therefore, ensure the subject is fully
relaxed in standing, palpate the lower abdomen and on
giving the instruction to contract, palpate for activate
muscle contraction. If the correct instruction has been
given and the other abdominal muscles, such as the more
superficial internal oblique, do not contract and a palpa-
ble contraction is palpated, it can be assumed to be that
of TrA. This can be tested in the absence of TrA weakness
on others and oneself. Examine in the same way as
described and a strong contraction will be felt with the
ASIS of the pelvis either not moving or moving minimally
in a superior or cephalad direction.
The highly admirable and enlightening work of
Richardson et al. (2002, 2004) has involved innovative
use of equipment and measurement techniques, such as
Doppler imaging of vibrations, electromyographic record-
ings and real-time ultrasound imaging in order to study
and demonstrate the function of TrA. Research and clinical
practice inform each other, but do not always share the
same methodologies for a variety of reasons such as cost,
availability and clinical pragmatism.
One alternative, low-technology technique includes the
use of a universal goniometer and a sphygmomanometer
– a pressure biofeedback unit (PBU) – with the cuff
being placed under the lumbar spine in either supine or
crook lying, and is described by Prentice (2004), citing a
plethora of authors, which the reader is referred to. Func-
tionally, however, these tests clearly do not involve TrA in
isolation from other abdominal muscles if active and cog-
nitive flattening of the lumbar lordosis is achieved and
maintained, as the abdominal mobilisers have been
brought into action. Many patients seen by physiothera-
pists may not be able to achieve the ability to conduct the
tests outlined by Prentice (2004) because of other mechan-
ical and pathological problems, but they can be used for
the more able subjects and for those requiring more
advanced rehabilitation.
Activation of TrA, independent of the global muscles, is
advocated for examination and exercise techniques in low
316
back pain (Richardson et al. 2002), but the physiothera-
pist would need to reason whether the anterior tilted
pelvis and weak or non-functioning TrA is primary or
secondary in nature, and address the primary problem in
order to prevent recurrence of the situation. It is beyond
the scope of this chapter to include all primary and other
reasons for developing mechanical low back pain, an
anterior tilted pelvis and a weak or non-functioning TrA
muscle, and it remains for the physiotherapist to ask the
right questions, about the right potential causations or
formulate the right hypotheses and progressively address
these with the right interventions that are safe, efficient
and effective.
Clinical note
Programmes to rehabilitate and stabilise the lumbo-pelvic
area, using predominantly TrA, have demonstrated
equivocal efficacy (Goldby et al. 2006; Critchley et al.
2007), but they do have some support within clinical
guidelines (Mercer et al. 2006; Savigny et al. 2009).
Analysis
As discussed above, an anterior tilted pelvis caused by a
weak or non-functioning TrA may cause low back pain
through, for example, increased facet joint compressive
and/or frictional forces. Equally and conversely, the same
muscle can be reflex-inhibited and develop weakness
owing to low back pain.
In a very weak contraction, the ASIS of the pelvis may
still not move, but this will be in the presence of an exces-
sive aĉd angle. In a partially weak TrA, the ASIS will move
superiorly or in a cephalad direction, either minimally or
sufficiently to recognise a difference in the aĉd angle in a
relaxed position in comparison with that of the contrac-
tion occurring on pelvic floor contraction. It is these two
aĉd angles that need recording for detecting and monitor-
ing the outcome of intervention. The value of the two
angles may equal each other in the presence of a very weak
TrA and a difference may occur as the muscle strengthens.
The value of the two angles may be observed to converge
again as it strengthens further and the relaxed aĉd angle
may be seen to normalise towards the normative value.
When the two values of relaxation and contraction are
seen to converge within the normative value range, the TrA
can be considered to be functioning in its stabilising role.
If the mobilising abdominal muscles are in need of reha-
bilitation and TrA has been demonstrated to be function-
ing in its stabilising role as described, it should be safe to
progress rehabilitation to include these muscles without
causing other adverse mechanical stresses.
It must be noted that attempts to intentionally contract
muscle and cognitively mobilise the pelvis actively will

induce mobilising muscle contraction and mask TrA con-
traction. The technique of inducing contraction of TrA as
described above can be utilised for early rehabilitation;
this will be described later.
Plan
It is important for the physiotherapist to always use accu-
rate prescription in rehabilitation, based upon the evi-
dence base from practice and research within literature or
theory, or guidelines, in the absence of research and evi-
dence base.
Technique
The core stabilising muscles are primarily type I slow-
twitch muscle fibres that best respond to time (Prentice
2004), including TrA, and suitable exercise should be low
load (i.e. 25% MVC), and longer hold periods (Mason
2008). Four levels of core stabilisation training pro-
grammes have been identified for athletes: level 1, stabili-
sation; level 2, stabilisation and strength; level 3, integrated
stabilisation strength; and level 4, explosive stabilisation
(Prentice 2004). If the athlete commences at a level where
they maintain stability and optimal neuromuscular
control and are progressed through the levels when they
have achieved mastery of the previous level (Prentice
2004), it seems reasonable to follow the same programme
and progression criteria for those patients requiring reha-
bilitation of TrA, albeit if most of these commence at level
1 and do not achieve beyond level 2.
Table 14.6 adopts the examples offered by Prentice
(2004) for level 1. If the ‘DRIFT’ (duration, repetition,
intensity, frequency, technique) acronym does not suit,
alternative, but similar, factors known as the FITT (fre-
quency, intensity, time (duration) and type of exercise)
principles can be adopted instead (Sanghvi 2008) and
may be easier to remember.
In practice and as discussed earlier, an alternative
to the draw-in manoeuvre is pelvic floor contraction.
Patients may find this easier to maintain when they
progress to crunches/partial sit-ups, including more func-
tional activity such as squats or lunge exercises. The same
applies to level 2 exercises made more difficult by con-
ducting, for example, sagittal and diagonal crunches/
partial sit-ups on a stability ball or functional propriocep-
tive neuromuscular facilitation (PNF) pattern exercises on
the same. The reader is referred to other texts such as
Prentice (2004) for more advanced levels of core stability
rehabilitation.
Evaluation
Evaluation is through reanalysis of the subjective and
objective examination markers such as pain, function,
lumbo-pelvic posture/position, measured comparative
Muscle imbalance Chapter 14
Table 14.6  Level 1 transversus abdominis
rehabilitation programme – adapted from Prentice
(2004)
Duration The duration of a contraction should be
calculated and checked to see if the same
can be repeatedly achieved with a few
seconds rest between each contraction. If
necessary, slightly reduce the length of
contraction time in order to afford greater
repetitions and progress time as soon as
possible
Repetition The number of repetitions should be high,
but may be determined by the actual
contraction time ability. If contraction of
only a few seconds can be achieved, these
should be undertaken on a repetition rate
of 10–12 repetitions
Intensity Intensity or resistance should be low
and the technique offered is sufficient in
supine lying, standing or prone lying i.e.
gravity-assisted, eliminated and resisted,
respectively
Frequency If the time period for available contraction
is calculated to be low, e.g. 10–20 s, then
hourly contractions would seem reasonable
with frequency possibly reducing as
contraction time ability increases, e.g. 60 s
contraction every 2–4 h
Technique In supine lying:
Do: Abdominal draw-in manoeuvre.
Progression can include sagittal, then
diagonal crunches/partial sit ups in crook
lying
pelvic levels and any other secondary related signs of
muscle imbalance. Evaluation determines whether inter-
vention is being effective by comparing the subjective and
objective markers and whether to continue or modify the
intervention. Progression criteria and progression tech-
niques should be as indicated in the plan above.
THE CERVICAL SPINE REGION
The cervical spine, as well as bearing the weight of the
head, is designed for mobility – principally for the posi-
tioning of the eyes’ line of vision – and therefore requires
movements with a high degree of precision. Subsequently,
the cervical muscles (in particular those of the upper
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 Tidy’s physiotherapy

cervical spine) are highly innervated (Middleditch and

Table 14.7  Cervical spine movements and their
Oliver 2005). The suboccipital muscles, in particular, have key muscles
a high concentration of muscle spindles (Peck et al. 1984)
and act as ‘proprioceptive monitors’ (Fernández-de-las-
Movement Muscles
Peñas et al. 2007). This presents its own potential prob-
lems. As with elsewhere in the body, there is usually a Flexion Sternocleidomastoid (working
trade-off between mobility and stability, but high motor bilaterally)
precision requires highly balanced motor function. The Draws head anteriorly (protracts)
increased innervation, essential for the motor control, not Scalenus anterior (working bilaterally)
only concerns motor output (descending pathways), but Deep cervical flexors
also necessitates increased sensory information (ascend- Longus colli (working bilaterally)
ing pathways) for feedback purposes, etc. but may then Longus capitis
make the head and neck more sensitive to the perception Flexes head on neck/upper cervical
of pain. Rectus capitis anterior
Other key differences in the anatomy of the cervical Flexes head on neck; stabilise C0–C1
spine compared with the lumbar spine, such as smaller
Extension Levator scapulae (working bilaterally)
vertebral bodies and thinner intervertebral discs, allow
Splenius cervicis (working bilaterally)
for greater mobility, but at the potential cost of stability
(Panjabi’s passive subsystem (Panjabi 2003)). Therefore, Trapezius (working bilaterally)
the role of the musculature (the active subsystem) is vitally Upper fibres
important as it contributes significantly to the stability Splenius capitis (working bilaterally)
of the cervical spine. Erector spinae (working bilaterally)
Rectus capitis posterior minor
Extend head on neck; stablise C0–C1;
Muscles proprioceptive
Rectus capitis posterior major
Movements of the cervical spine are complex as they are Extend head on neck; stablise C0–C1;
not single joint articulations and can also be differentiated proprioceptive
into upper cervical or lower cervical movements, with the Obliquus capitis superior
head being able to articulate on the neck. The assessment Extend head on neck; stablise C0–C1
of the quality of the movement is pertinent. Table 14.7
outlines the key muscles associated with movements of Protraction Sternocleidomastoid (working
the cervical spine and Table 14.8 highlights those muscles bilaterally)
that predominantly act as stabilisers and mobilisers. Longus capitis

Retraction Deep cervical flexors

Trapezius
Deep cervical flexors
Rotation Semispinalis cervicis
In the cervical spine, the deep cervical flexors (see Figure Multifidus/rotatores
14.10) – also referred to as the deep neck flexors – have Scalenus anterior
been the subject of much research and clinical focus, Splenius cervicis
similar to TrA in the lumbar spine (Jull et al. 1999, 2004, Sternocleidomastoid
2008). While named ‘flexors’, their role also includes sta- Splenius capitis
bilising the position of the head and upper cervical spine Obliquus capitis inferior
during prolonged postures and repeated movements, Rectus capitis posterior major
aided by their close approximation to the spine and pre-
dominantly parallel fibre direction. Their function has Lateral Scalenus anterior
been shown to be impaired in people with cervicogenic flexion Scalenus medius
headaches, whiplash associated disorder (WAD) and Scalenus posterior
insidious neck pain (Jull et al. 1999, 2004), with delay in Splenius cervicis
activation/inhibition, weakness and fatigue demonstrated. Levator scapulae
The mechanisms for this dysfunction include pain inhibi- Sternocleidomastoid
tion and altered postural and movement behaviour. The
multifidus are less prominent in the cervical spine com-
pared with the lumbar spine and, therefore, it appears less
emphasis is placed on their stabilising role and contribu-
tion to pain and pathology in the literature.

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Table 14.8  Cervical spine mobilisers and stabilisers

Local stabilisers Global stabilisers Global mobilisers

Anterior: Anterior: Scalenes

Longus capitis Longus colli Sternocleidomastoid hyoids
Rectus capitis anterior Posterior: Levator scapulae
Posterior: Superficial multifidus Upper trapezius
Rectus capitis posterior minor Spinalis Suboccipital extensors
Rectus capitis posterior major Semispinalis (Ligamentum nuchae – although not a muscle,
Obliquus capitis superior it is significant to note as it can become
Deep multifidus tight)

Rectus capitis anterior Poking chin

Rectus capitis lateralis
Longus capitis

Levator scapulae

Longus coli Upper trapezius

Deep neck flexors
Anterior
Middle Scalene
Posterior
Phrenic nerve

Figure 14.11  Forward head posture demonstrating the

poking chin and muscle balance changes.
Figure 14.10  Anatomy of deep cervical flexors.

Posture
Forward head posture (FHP) – or ‘poking chin’ – has been
associated with conditions of the head and neck, such as
headaches (Watson and Trott 1993; Fernández-de-las-
Peñas et al. 2007) and WAD (Nilsson and Söderlund
2005), but may also be associated with poor sitting and
working conditions. The weakened and/or lengthened
deep cervical flexors struggle to maintain an upright
posture against overactive and/or shortened posterior
extensors structures, such as the trapezius (see Figure
14.11). However, the involvement of the suboccipital
muscles is disputed as, while it has been reported they
can possess painful myofascial trigger points in indi­
viduals with FHP and chronic tension-type headaches
(Fernández-de-las-Peñas et al. 2006), atrophy has also
been demonstrated in some chronic neck pain subjects
(Hallgren et al. 1994). Of course, posture needs to
be assessed globally and in context of the presenting
problem, taking into account the wide range of what is
considered ‘normal’.
Clinical note
This may be the proverbial ‘chicken and egg’ situation:
Which came first?
• Pain inhibition, weakness and fatigue of the deep
cervical flexors, following trauma or pathology, for
example, results in FHP.
Or
• FHP is adopted either in an attempt to gain pain relief
following trauma/pathology or owing to activities,
such as prolonged poor sitting posture in response to
work demands or video game playing. This may then
result in pain inhibition, weakness and fatigue of the
deep cervical flexors.
Or
• FHP is pre-existing, for example, owing to lumbar
spine problems or pathology.

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 Tidy’s physiotherapy

Table 14.9  Patient example of cervical muscle imbalance using the SOAPE framework

Subjective Objective Analysis Plan Evaluation

Pain posterior neck Forward head posture Weak deep Re-train deep cervical Re-assess C-CFT
and headache ↓ Cervical range of cervical flexors (± PBU) and ROM,
occipital area. movement (ROM), flexors Gentle stretch then progress
Worse after day especially flexion Tight trapezius trapezius exercises
at work (using and rotation (end-range flexion)
computer) C-CFT = unable to Postural/ergonomic
hold for 10 s advice

FHP may also be associated with shortening and over-
activity of sternocleidomastoid and the scalenes (particu-
larly the anterior). The superficial cervical flexors are
thought to compensate for the poor motor control and
have been show to be used more by those with WAD
or insidious neck pain than in asymptomatic subjects
(Jull et al. 2004). As the superficial flexors are preferen-
tially biased to being mobilisers rather than stabilisers it
appears that they are more susceptible to fatigue and pain
when over-worked (Watson and Trott 1993), adding to the
general irritability in the neck and, potentially, the devel-
opment of myofascial trigger points (Roth et al. 2007).
Assessment and treatment
The well-documented cranio-cervical flexion test (C-CFT)
has been developed and validated to assess the impair-
ment of the deep cervical flexors (Jull et al. 1999, 2004,
2008). This involves flexing (as in nodding) the head on
the neck so that the chin is gently tucked in. A PBU is used
in order to focus on low-load endurance and provide a
more objective measure, while compensatory strategies,
such as the use of sternocleidomastoid and platysma (the
‘shaving’ muscle), are noted but discouraged. The same
exercise performed as a training regime using the PBU
with a starting pressure of 20 mmHg and held for 10
seconds for 10 repetitions, then increasing in 2 mmHg
increments up to 30 mmHg, has demonstrated a reduc-
tion in headache and neck pain in subjects with cer­
vicogenic headaches (Jull et al. 2002) and has been
recommended in the management of WAD (Moore et al.
2005). The author’s clinical experience has demonstrated
that the deep cervical flexors can be assessed and treated
in a similar manner even without a PBU, only using
careful instruction, observation and motivation. Table
14.9 illustrates an example patient’s problem documented
using the SOAPE framework.
THE SHOULDER COMPLEX
The shoulder complex is made up of four key articulations:
the sternoclavicular, acromioclavicular, scapulo-thoracic
and glenohumeral joints. In addition to this, within the
kinetic chain, it is important to consider the cervical and
thoracic spinal joints when assessing movement dysfunc-
tion in this area. Considering Panjabi’s (2003) model,
the passive subsystem providing stability to the gleno-
humeral joint consists of the glenohumeral ligaments, the
glenoid labrum, passive muscle stiffness of the rotator cuff
muscles as they insert into the capsule and negative intra-
articular pressure within the joint (Hess 2000). Likewise,
the bony strut of the clavicle with its capsular and liga-
mentous attachments at the acromioclavicular and sterno-
clavicular joints provides stability for the scapula (Kibler
and Sciascia 2010). Examination and assessment of these
structures, as indicated by the subjective history of the
patient, is necessary as part of the routine musculoskeletal
assessment.
As the focus of this chapter is muscle imbalance, an
overview of movement at the shoulder complex and the
key muscles providing static and dynamic stability will be
discussed as part of the active subsystem referred to by
Panjabi (2003).
Scapulo-humeral rhythm
Despite controversy in the literature over the ratio of
scapula rhythm (Freedman and Munro 1966; Doody et al.
1970; Poppen and Walker 1976; Bagg and Forrest 1988;
McClure et al. 2001), it is commonly reported, in accord-
ance with Inman (1944), that the scapulo-humeral rhythm
has a ratio of 2 : 1. Inman (1944) states that the scapula
seeks a precise position of stability during the first
30°–60° of movement (the setting phase) followed by a
constant relationship of humeral to scapular motion of
2 : 1, whereby between 30° and 170° for every 15° of
motion, 10° occurs at the glenohumeral joint and 5° at
the scapula-thoracic joint. This movement is accompanied
by clavicular movements at the sternoclavicular joint in
the early part of range and at the acromioclavicular joint
both early and late in the range of elevation.
Functionally, the scapula provides a stable base for
the muscle attachments to the glenohumeral joint and
serves to maintain the correct length tension relationship
of these muscles (rotator cuff, teres major, deltoid,

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coraco-brachialis, long head of biceps). Dynamically, its Muscles acting on the  

function is to upwardly rotate in order to orientate the
glenoid fossa in an upward forward and lateral position
and to tilt posteriorly and externally rotate (Kibler and
Sciascia 2010). These movements allow the clearance of
the acromion from the moving arm and maintenance of
the glenoid as a congruent socket for the moving arm. This
allows greater movement of the upper limb and elevates
the acromion such that there is adequate space in the
subacromial and coraco-acromial arches to avoid impinge-
ment of soft tissue structures within these spaces.
At the glenohumeral joint, the stabilising muscles
maintain and allow fine control of movement of the
humerus on the glenoid. Slight lateral rotation of the
humeral head is initiated in the early phase of abduction.
This should continue throughout the range as the scapula
upwardly rotates (Comerford and Kinetic Control 2001).
The lateral rotation of the humerus on elevation of the
arm allows for greater space between the greater tubercle
and the acromion.
Integral to this co-ordination of movement between the
scapulo-thoracic and glenohumeral joints at the shoulder
complex is motor control, as discussed earlier.
scapulo-thoracic joint
The muscles of trapezius and serratus anterior form the
proximal force couple and in their stability role maintain
the scapula in a stable position on the chest wall. In
dynamic stability, the key muscles which control upward
rotation of the scapula are the upper and lower fibres of
trapezius and serratus anterior (Figure 14.12). Addition-
ally, the serratus anterior helps produce posterior tilt and
external rotation of the scapula while stabilising the
medial border and inferior angle to prevent scapula
winging (Kibler and Sciascia 2010).
Table 14.10 indicates the muscles acting on the scapulo-
thoracic joint, their agonist actions and their primary
roles as mobilisers or stabilisers. As discussed earlier, the
stabiliser muscles are expected to be recruited earlier
than the mobilisers (Sahrmann 1987; Richardson 1992;
Comerford and Mottram 2001). Muscle imbalance at the
scapulo-thoracic joint can be seen by the dominance of
the mobiliser muscles where the stabilisers are weak or
slower to be recruited. The rhomboids, levator scapulae
and pectoralis minor muscles, although they have a minor

Table 14.10  Scapulo-thoracic joint muscles

Action Muscles Primary

muscle
role

Upper Elevation Upper trapezius Local/global

trapezius stabiliser
Levator scapula Global
mobiliser

Depression Lower trapezius Local

stabiliser

Adduction Middle Local

trapezius stabiliser
Rhomboids Global
mobiliser

Abduction Serratus Global

anterior stabiliser
Pectoralis minor Global
mobiliser
Serratus Upward rotation Serratus Local/global
anterior
anterior stabilisers
Trapezius

Lower Downward rotation Rhomboids Global

trapezius Levator mobilisers
scapulae
Figure 14.12  The key muscles controlling rotation of the Pectoralis minor
scapula, which act as a ‘force couple’.

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 Tidy’s physiotherapy

stability role of the scapula on the chest wall, primarily act and depression to counteract the upward pull of deltoid
as mobilisers of the scapula. Because of the synergistic and therefore maintain the humeral head on the glenoid
actions of rhomboids and levator scapulae with trapezius cavity (i.e. in its neutral zone). This relationship continues
in relation to adduction and elevation, they can become between the rotator cuff and deltoid throughout elevation
dominant when trapezius is weak on these activities and of the arm (Figure 14.13). Should there be any weakness
therefore can limit upward rotation with their antagonist in the rotator cuff such that the balance of forces becomes
role as downward rotators. Likewise, pectoralis minor can unequal, this can result in a greater pull from deltoid
become dominant and shortened in its synergist activity such that the humeral head moves superiorly under the
of abduction of the scapula with serratus anterior leading acromion leading to impingement.
to an increase in its activity of downward rotation of the At the gleno humeral joint, the global mobilisers
scapula when serratus anterior is weak. This will limit (pectoralis major and latissimus dorsi) can be recruited
upward rotation. It must not be forgotten that latissimus early and become dominant when the local stabiliser
dorsi through its attachment onto the inferior angle of the
scapula may also have a downward rotation action on the
scapula.
Table 14.11  Key roles of the muscles acting on the
This lack of upward rotation, as indicated earlier, leads
glenohumeral joint
to narrowing of the subacromial and coraco-acromial
arches and, hence, the risk of impingement. Ludewig
Local Global Global
and Cook (2000) and Cools et  al. (2003) have identi-
fied alterations of activation sequencing patterns and stabilisers stabilisers mobilisers
strength of the scapula stabilising muscles in patients Supraspinatus Teres major Latissimus dorsi
with impingement. Infraspinatus Deltoid Teres major
Teres minor Coracobrachialis Pectoralis major
Subscapularis Long head Teres minor
Muscles acting on the   biceps Infraspinatus
glenohumeral joint Some fibres of Short head
subscapularis, biceps
Table 14.11 indicates the key roles of the muscles acting
infraspinatus Long head
on the gleno humeral joint
and teres triceps
The forces of the rotator cuff (supraspinatus, subscapu-
minor
laris, infraspinatus and teres minor) provide compression

Deltoid Supraspinatus

Infraspinatus

Subscapularis

Teres minor

Front view Back view

Figure 14.13  Action of the rotator cuff and deltoid.

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 Muscle imbalance Chapter 14

(subscapularis) is weak. Although infraspinatus and teres Causes of shoulder pain

minor’s key role is stability as part of the rotator cuff,
The link between impingement symptoms and shoulder
there can be a tendency for these muscles to take on a
instability is well established (Cools et al. 2007; Hanchard
mobilising role and be seen to lack extensibility, which
et al. 2004). Excessive humeral head translation can lead
can lead to anterior translation of the humeral head
to narrowing of the subacromial or coracoacromial spaces.
(Comerford and Kinetic Control 2001) and glenohumeral
Identification of functional problems that lead to impinge-
internal rotation deficit (GIRD). Rotator cuff weakness
ment, i.e. dysfunction of the position of the humeral head
may be demonstrated for many reasons, for example
on the glenoid or scapula dyskinesis (Cools et al. 2003;
actual injury, disuse atrophy, inhibition owing to pain or
Kibler and Sciascia 2010), is essential to the choice of
decreased muscle activation patterns owing to lack of a
muscle balance techniques for treatment. Signs of primary
stable base (Kibler and Sciascia 2010). It is therefore essen-
impingement (a structural narrowing of the subacromial
tial that a complete musculoskeletal assessment is carried
space, for example acromioclavicular arthropathy, type I
out to identify whether weakness is a result of muscle
acromion, swelling of the soft tissue in the subacromial
imbalance or some other cause.
space (Cools et al. 2003)) or structural instability of the
A simplification of the muscles commonly identified in
glenohumeral joint (Type I and Type II Stanmore classifi-
muscle imbalance of the shoulder complex is presented in
cation (Lewis et al. 2004)) must be ruled out.
Table 14.12.
The SOAPE process (Baxter 2003) is used to discuss
common clinical presentations.
Clinical presentations of  
the shoulder complex Subjective
A person with impingement symptoms can present with:
The following provides a guide with regard to typical
findings relating to muscle imbalance around the shoulder • pain C5 dermatome;
complex and its link with impingement. Further reading • painful arc;
is suggested to gain a full understanding of the assessment • pain aggravated by repetitive overhead activity.
and treatment principles relating to muscle imbalance for
this region. An evidence-based approach to the diagnosis Objective and analysis
assessment and physiotherapeutic management of shoul-
Typical movement faults identified are:
der impingement syndrome is provided by Hanchard
et al. (2004). • scapula – see Tables 14.13 and 14.14, and Figure
14.14;
• glenohumeral joint – see Table 14.15.
Table 14.12  Commonly affected muscles of
the shoulder complex

Joint ‘Goodies’ ‘Baddies’

Muscles expected Muscles which

to initiate and take over
control ‘normal’ when
scapula ‘goodies’
movement or become long
maintain the and weak
humeral head
centred on the
glenoid

Scapulo- Upper and lower Levator scapulae

humeral trapezius Rhomboid minor
Serratus anterior and major
Pectoralis minor

Gleno- Supraspinatus Latissimus dorsi

humeral Subscapularis Teres major
Teres minor Pectoralis major
Infraspinatus Deltoid
Figure 14.14  Pseudo-winging of the scapula.

323
 Tidy’s physiotherapy
Table 14.13  On concentric movement of arm
elevation
Objective signs
Early movement of scapula
where scapula elevates
rather than upwardly
rotates on abduction
Excessive scapula elevation
or protraction on flexion
At end-range, scapula
inferior angle does not
move around to mid
axillary line
Downward rather than
upward rotation of
scapula
Winging of the scapula
Table 14.14  Eccentric movement
Objective signs
Excessive downward rotation
of scapula seen as scapula
drops on lowering at 90°
flexion or 60° abduction
Winging of the scapula
324
Table 14.15  Glenohumeral joint
Objective signs Analysis
Analysis
Excessive inferior Weakness of supraspinatus
Early recruitment/ translation of humerus in providing caudal glide
overactivity of upper noted as deep posterior at the humeral head to
fibres of trapezius and/ acromial dimple and bulge maintain humeral head
or levator scapula of humeral head in axilla centred on the glenoid
Weakness of lower fibres Excessive medial rotation Overactivity/shortening
of trapezius such that on flexion of latissimus dorsi and/or
the pull of upper pectoralis major
fibres of trapezius and
serratus anterior is not Absent or late lateral Late recruitment of
counterbalanced rotation on abduction infraspinatus and/or teres
minor
Shortening/overactivity
of downward rotation
of the scapula or
latissimus dorsi
Weakness of upward
rotators and
shortening/early
recruitment of
downward rotators
Whole medial border –
weakness of serratus
anterior
Psuedo-winging (see
Figure 14.14), i.e.
inferior angle only
– shortening of
pectoralis minor Figure 14.15  Poor scapular control on eccentric lowering of
the arm.
Plan (Treatment)
Once a hypothesis has been reached regarding the likely
Analysis muscle dysfunction, treatment commences with monitor-
ing the patient’s symptoms on facilitating the neutral posi-
Early recruitment of tion of the affected joint with low load activity to recruit
downward rotators in an the weakened muscle groups, for example stabilisation of
attempt to substitute for the scapula on the chest wall. Once this is achieved, the
weak serratus anterior individual is challenged to control the scapula position
and trapezius during
on movement, for example flexion or lateral rotation
eccentric muscle activity
(Figures 14.15, 14.16 and 14.17).
Weakness of serratus All exercises must be pain-free and are required to be
anterior and lower fibres performed without fatigue of the muscles being facilitated
of trapezius resulting in or substitution by the synergists. Functional movements
poor scapula stability relating to the patient’s activities are encouraged to facili-
(Figure 14.15) tate compliance. Studies to identify recruitment patterns
of the scapular muscles and the optimal shoulder exercises
used to facilitate scapular control have been carried out by
Kibler et al. (2008), Cools et al. (2003, 2007) and De May
et al. (2009).

Figure 14.16  Scapula stabilisation is encouraged on active
forward flexion of the arm aiming to avoid elevation of the
shoulder girdle and to facilitate normal timing of the upward
rotation of the scapula.
Figure 14.17  Scapula neutral has been facilitated on the left
and the individual is encouraged to maintain this position on
active lateral rotation of the left arm. Also note the increased
skin creases in the thoraco-lumbar region demonstrating a
‘give’ in this region, possibly owing to poor spinal postural
control.
Once pain-free, functional movement is achieved any
residual muscle tightness is addressed with stretching tech-
niques specific to the muscle affected, making sure that
the joints remain in their neutral zone. Postural correction
is facilitated and encouraged throughout treatment.
Evaluation
There is an extensive body of literature relating to kinemat-
ics of the shoulder complex using complex and expensive
motion analysis systems to evaluate movement (Imtiyaz
and Kelly 2001; Borstad and Ludewig 2002; Lin et al.
2005) and it is still growing. Monitoring of scapula posi-
tion and humeral head position in the clinical situation
Muscle imbalance Chapter 14
tends to be by visual observation and can be difficult
to measure objectively. Video analysis can assist with
this process and provide visual feedback to the patient to
facilitate normal movement. Evaluation of reduction of
pain measured by the numerical rating scale or visual
analogue scale on correction of movement dysfunction is
the most commonly used outcome measure in the clinical
situation.
THE KNEE
There is an inherent imbalance between the major muscle
groups of the lower limb that affect both the hip and, in
particular, the knee, as the quadriceps are usually stronger
than the hamstrings, as to be expected by their greater
size. The ratio of the strength of the hamstrings to the
strength of the quadriceps can be expressed as the H : Q
ratio; the normal range being 50–80% (Rosene et al. 2001;
Norris 2004). This, along with their increased eccentric
contraction workload, can explain why the hamstrings are
more commonly injured in sports, for example. Further-
more, this ‘natural’ imbalance can be increased by training
regimes that favour the quadriceps, such as squats and the
leg press.
Vastus medialis oblique
Within the quadriceps group and specifically affecting
the patellofemoral joint, there exists another potential
imbalance. The vastus lateralis (VL) stabilise and control
the lateral glide (or often termed ‘tracking’) of the patella,
while the medial glide is controlled by the vastus medialis,
specifically the oblique fibres (vastus medialis oblique
(VMO)). These oblique fibres have been reported to be
orientated approximately 50° medially compared with
less than 20° for the ‘longus’ fibres (the so-called vastus
medialis longus (VML)). This apparent difference has
caused debate as to whether VMO is anatomically, as
well as functionally, distinct from VML, as it is suggested
that VML extends the knee instead (Smith et al. 2009).
VMO activity is thought to be most critical during the
final 20° extension/first 20° flexion (see Figure 14.18), as
it ensures optimal seating of the patella within the
trochlear.
As it has also been demonstrated that small changes
in VMO activity can have significant effects on patellar
position, there has been much interest in assessing and
treating the VMO. VMO has been reported as being
far more easily inhibited than VL in response to pain,
whereas VMO normally exhibits faster reflex response
times than VL, such that patellofemoral pain may become
a secondary feature of other knee trauma or pathology
(McConnell 1996).
325
 Tidy’s physiotherapy

A B

Figure 14.18  (a, b) Vastus medialis oblique (highlighted) working during extension.

Q angle
Assessment
However, the stability of the patella is not without influ-
Rectus ence from other factors. Owing to the direction of action
femoris of the quadriceps (represented by a line from the ASIS to
(vastus the centre of the patella, or longitudinal axis of the femur)
intermedius relative to the direction of pull from their attachment on
behind) the tibia via the patella tendon (represented by a line
Vastus along the longitudinal axis of the tibia) – termed the Q
medialis angle (see Figure 14.19) – there is a resultant valgus vector.
Vastus The Q angle is usually described as being approximately
lateralis 15° for men and approximately 20° for women. An
Valgus
vector increased angle is thought to be a risk factor for patel-
lofemoral pain (McConnell 1996; Powers 2003). This,
combined with the presence of the iliotibial band (ITB)
– which in itself can become tight – means that the
VMO, as the sole medial stabiliser, can be at a significant
disadvantage.
The quadriceps are also commonly prone to tightness
(Mason 2008) and consideration needs to be given to
rectus femoris as it also crosses the hip. Figure 14.20
illustrates the resultant compressive biomechanical forces
exerted on the patellofemoral joint when the knee is
Figure 14.19  Illustration of the pull of the quadriceps and flexed and this is increased if the quadriceps are too
the Q angle. tight or too short (passively insufficient). In addition to

326

Table 14.16  Patient example of vastus medialus oblique (VMO) muscle imbalance using the SOAPE framework
Subjective Objective
Left anterior Full range of movement but pain
knee pain end-range
Pain on stairs, Pain on small knee bend test
descent Left VMO atrophy
worse Tight left iliotibial band (ITB)
Reduced left patella medial glide
Directional pull of
quadriceps femoris
Distal femur
Resultant force producing a decreased
patellofemoral joint space and risk of
patellofemoral joint irritation and degeneration
Proximal tibia
Equal and opposite
directional pull of
ligamentum patella
Figure 14.20  Resolution of forces; the resultant force
producing prospective patellofemoral problems caused by a
passively insufficient rectus femoris.
this compression, quadriceps tightness may lead to the
patella sitting higher in relation to the femoral trochlear
(patella alta) and therefore affect its engagement and
smooth movement. Subjectively, the patient may com-
plain of anterior knee pain and, objectively, there will
be evidence of shortened muscles in a passive prone
lying knee bend and possibly on accessory movements
of the patellofemoral joint with potential patella mala-
lignment present. The Thomas test may be a useful
assessment tool to assess the involvement of rectus
femoris in relation to iliopsoas, as well as observing
medio-lateral deviation (i.e. tight adductors or lateral
structures such as ITB, which can be then assessed using
Ober’s test).
Treatment/management
VMO rehabilitation exercises, such as end-range squats,
have long been recommended (McConnell 1996) and
there has been some positive research supporting their
use (Cowan et al. 2002; Crossley et al. 2002), although,
Muscle imbalance Chapter 14
Analysis Plan Evaluation
Increased lateral Patella taping Retest small knee bend
tracking from – medial with tape on (painfree =
VMO/ITB glide positive result)
imbalance VMO squat Retest Ober’s
ITB stretch Progress squat to
single-leg, then stepping
overall, evidence for the effectiveness of exercise therapy
for patellofemoral pain syndrome has been described as
limited (Heintjes et al. 2003).
Adjuncts to VMO training include ITB/lateral reti­
naculum stretching and patellar taping, which has been
claimed to improve lateral tracking of the patella and the
proprioceptive stimulation of the VMO, although the evi-
dence for its efficacy and mechanism has been disputed
(Clark et al. 2000; Tobin and Robinson 2000; Hinman
et al. 2003; Christou 2004).
In addition, the effect of other, more distal influences
(e.g. foot posture) or proximal influences, such as in­­
cluding the gluteus medius’ contribution to maintaining
lower limb posture and knee stability (Cowan et al.
2002), need to be addressed. Table 14.16 illustrates an
example patient’s problem, documented using the SOAPE
framework.
Clinical note
As in most areas of physiotherapy (if not healthcare in
general), myths and controversy surround the subject and
interventions can become fads and accepted en masse as
a panacea; muscle imbalance (and ‘core stability’
– defined later) are, perhaps, the epitome of this (see
Lederman 2007; Bee 2010). While physiotherapy may
appear an ‘art form’ in application of practice, it is the
science that has to be evaluated and a physiotherapist
ignores either at his/her peril.
Unfortunately this is usually propagated by an
imbalance in the literature itself and, perhaps, its
subsequent evaluation. Clinical observations and early
research indicated that certain patient populations
exhibited changes in muscle function or balance (i.e.
those with low back pain had TrA dysfunction compared
with asymptomatic subjects). This seemed to suggest that
this could be reversed/addressed and various interventions
(i.e. exercises) were proposed, many of which were
adopted by clinicians without substantial evidence of their
efficacy. Even now, the evidence supporting interventions
addressing muscle balance is still lacking.
327
 Tidy’s physiotherapy

ACKNOWLEDGEMENTS

We are very fortunate and appreciative of having had the opportunity to work closely with colleagues over the years who
have entered great informal and non-threatening clinical discussion and debate. One physiotherapist who particularly
engaged in this was Jane Brazendale (clinical lead physiotherapist in women’s health). She was the first to openly discuss
and approve ideas regarding the TrA/pelvic level measurement in the early years of the last decade. We have all been
developed by our patients, education and our colleagues, and we thank our colleagues for their healthy contributions
to peer development. Alec would also like to thank Sìne Rickard, his wife and physiotherapist, who provided much
needed support while heavily pregnant.

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L.S., 1999. Travell and Simons’
Myofascial Pain and Dysfunction:
Upper Half of Body. Lippincott
Williams & Wilkins, Baltimore.
Smith, T.O., Nichols, R., Harle, D.,
et al., 2009. Do the vastus medialis
obliquus and vastus medialis
longus really exist? A systematic
review. Clin Anat 22, 183–199.
Standring, S. (Ed.), 2005. Gray’s
Anatomy: The Anatomical Basis
for Clinical Practice, thirty-ninth ed.
Churchill Livingstone, Edinburgh.
Tabary, J.C., Tabary, C., Tardieu, C.,
et al., 1972. Physiological and
structural changes in the cat soleus
muscle due to immobilization
at different lengths by plaster casts.
J Physiol 224, 231–244.
Tobin, S., Robinson, G., 2000. The
effect of McConnell’s vastus lateralis
inhibition taping technique on
vastus lateralis and vastus medialis
obliquus activity. Physiotherapy 86
(4), 173–183.
Walsh, M., Woodhouse, L.J., Thomas,
S.G., et al., 1998. Physical
impairments and functional
limitations: A comparison of
individuals 1 year after total knee
arthroplasty with control subjects.
Phys Ther 78 (3), 248–258.
Watson, D.H., Trott, P.H., 1993.
Cervical headache: an investigation
of natural head posture and upper
cervical flexor muscle performance.
Cephalalgia 13, 272–284.
White SG, Sahrmann, SA, 1994. A
movement system balance approach
to management of musculoskeletal
pain. In: Twomey, L.T., Taylor, J.R.
(Eds), Physical Therapy of the
Cervical and Thoracic Spine.
Churchill Livingstone,
New York.
Williams, P.E., Goldspink, G., 1978.
Changes in sarcomere length and
physiological properties in
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Connective tissue changes in
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343–350.
 Chapter
Biomechanics
Jim Richards, Ambreen Chohan and Renuka Erande
INTRODUCTION
This chapter will take you through an introduction to
clinical gait analysis, definitions and detailed descriptions
of the movement and force patterns found during walking,
and the mathematical basis of how joint movement,
muscle forces and power may be calculated. More infor-
mation about clinical biomechanics is available in the
textbook Biomechanics in Clinic and Research: An Interactive
Teaching and Learning Course (Richards 2008).
Clinical gait analysis
In 1953, Saunders and co-workers referred to the major
determinants in normal gait and applied these to
the assessment of pathological gait. Inman (1966, 1967)
and Murray (1967) both published detailed analyses
on the kinematics and conservation of energy during
human locomotion, and these are resources still fre-
quently referred to. Inman et al. (1981) later published
Human Walking, a comprehensive textbook on human
locomotion.
Brand and Crowninshield (1981) highlighted the dis-
tinction between the use of biomechanical techniques to
‘diagnose’ or ‘evaluate’ clinical problems. The authors
stated: ‘Evaluate, in contrast to diagnose, means to place a
value on something. Many medical tests are of this variety
and instead of distinguishing diseases, help determine the
severity of the disease or evaluate one parameter of the
disease. Biomechanical tests at present are of this variety’.
Brand and Crowninshield also gave a guide of six require-
ments for tools used in patient evaluation:
1. The measured parameter(s) must correlate well
with the patient’s functional capacity
2. The measured parameter must not be directly
observable and semi-quantifiable by the physician or
therapist
15 
3. The measured parameters must clearly distinguish
between normal and abnormal
4. The measurement technique must not significantly
alter the performance of the evaluated activity
5. The measurement must be accurate and reproducible
6. The results must be communicated in a form which
is readily identifiable.
Brand and Crowninshield stated: ‘It is clear to us that
most methods of assessing gait do not meet all of these
criteria. We believe that it is for this reason that they are
not widely used.’
Advances in biomechanical assessment in the last 30
years have been considerable. The description of normal
gait in terms of movement and forces about joints is now
commonplace. The relationship between normal gait pat-
terns and normal function is also well supported in both
scientific articles and textbooks (Bruckner 1998; Rose
and Gamble 2005; Perry 2010, Levine et al. 2012). This
allows deviations in gait patterns to be studied in relation
to changes in function in subjects with particular patholo-
gies. It is possible for a clinician or physician to subjec-
tively study gait, but the value and repeatability of this
type of assessment is questionable owing to poor inter-
and intra-tester reliability (Pomeroy et al. 2003). It is
impossible for one individual to study simultaneously, by
observation alone, the movement pattern of all the main
joints involved during an activity like walking. Studying
movement patterns using objective motion analysis
allows information to be gathered simultaneously with
known accuracy and reliability. In this way, changes in
movement patterns owing to intervention by physical
therapists and surgeons may be assessed unequivocally.
Most motion analysis systems now report on the joint
kinematics of the recorded individual and also contain
the mean for normal data on the same graph, allowing a
direct comparison of the individual’s movement pattern
in relation to a predefined normal. Such information is
also available in Clinical Gait Analysis: Theory and Practice
(Kirtley 2005).
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 Tidy’s physiotherapy
Patrick (1991) reviewed the use of movement analysis
laboratory investigations in assisting decision-making for
the physician and clinician. Patrick concluded that the
reasons for the use of such facilities not being widespread
were owing to:
• the time of analysis being considerable;
• bioengineers designing systems and presenting
results for researchers and not clinicians;
• a lack of understanding by physicians and clinicians
of applied mechanics and its relevance to assessment
of treatment outcome.
A common argument against movement analysis labo-
ratories has been cost. The cost of movement analysis
equipment and its potential use in the clinical setting has
been reported (Bell et al. 1996). Indeed, a broader ques-
tion could be put to any clinical assessment or treatment
that requires the use of technology. One example of this
is the relative cost of radiography to movement analysis
equipment, which, in comparison, is modest. Gage (1994)
claimed that gait analysis costs are comparable with
magnetic resonance imaging (MRI) or computed axial
tomography (CAT) scans. Gage also stated that the use of
movement analysis, as a detailed form of assessment, may
have wider cost benefits and improve clinical services
more than first realised.
Bell et al. (1995) highlighted the use of a holistic
approach to motion analysis, which included muscle
performance, joint range of motion, kinematic and
kinetic parameters of gait. This holistic approach may be
applied to many pathologies to give a detailed assess-
ment of pathology and the subsequent effects of
treatment.
Many of the techniques of collection and analysing
human locomotion have been applied to clinical practice.
This has led to a more detailed clinical assessment
of therapeutic and surgical intervention, which is becom-
ing increasingly important in the age of evidence-based
practice.
KINEMATICS
The gait cycle
Kinematics is the study of the movement of the body and
body segments with no reference to the forces which may
be acting. For instance, during normal walking there is an
obvious division in the length of time that the foot is in
contact with the ground and the period when it is not.
These are known as the ‘stance phase’ (approximately 60%
of the gait cycle) and the ‘swing phase’ (approximately
40% of the gait cycle) respectively.
• The stance phase can be subdivided into: heel strike,
foot flat, mid-stance, heel off and toe off.
• The swing phase can be subdivided into: early swing,
mid-swing and late swing.
332
Spatial and temporal parameters  
of gait
The simplest way to look at the kinematics during walking
is by studying foot positions (spatial parameters) and
times (temporal parameters).
Spatial parameters
We can display spatial parameters of foot contact during
gait as a series of footprints (Figure 15.1). These can also
be defined as follows:
• step length – the distance between two consecutive
heel strikes;
• stride length – the distance between two consecutive
heel strikes by the same leg;
• foot angle or angle of gait – the angle of foot
orientation away from the line of progression;
• base width or base of gait – the medial lateral distance
between the centre of each heel during gait.
Temporal parameters
We can display temporal parameters of heel strike and toe
off pictorially (Figure 15.1). These can also be defined as
follows:
• step time – the time between two consecutive heel strikes;
• stride time – the time between two consecutive heel
strikes by the same leg, one complete gait cycle;
• single support – the time over which the body is
supported by only one leg;
• double support – the time over which the body is
supported by both legs;
• swing time – the time taken for the leg to swing through
while the body is in single support on the other leg;
• total support – the total time a foot is in contact with
the ground during one complete gait cycle.
Two other parameters may easily be calculated using this
information: cadence and velocity. The cadence is the number
of steps taken in a given time, usually steps per minute.
Number of steps
• Cadence (steps/min) =
Time (min)
Velocity may be calculated by:
step length (m) × cadence 
steps 
 min 
• Velocity (m/s) =
60 (number of seconds in one minute)
Symmetry can also be assessed by dividing the value of a
parameter found for the left over that of the right:
step length for left
• Symmetry of step length =
step length for right
These parameters, although simple, can be a very useful
means of outcome assessment. It must be noted, however,
that these may not always be appropriate for some more
complex pathological gait patterns (Wall et al. 1987). For
example, the features of Parkinsonian gait can include a
reduction in stride length and velocity, and an increase
 Biomechanics Chapter 15

Stride length

Step length Foot angle

Base width

Heel Heel
strike Toe off strike

10% 10%
of 40% of gait cycle of 40% of gait cycle
gait cycle gait cycle

Toe off Heel

strike
Figure 15.1  Spatial and temporal parameters.

in base width. However, this results in a characteristic

shuffling gait which makes it hard to determine the
events of heel strike and toe off. For further information
on Parkinson’s disease, please refer to Chapter 24.

ANALYSIS OF JOINT MOVEMENT

DURING GAIT

Human walking allows a smooth and efficient progression Segment

of the body’s centre of mass (Inman 1967). To achieve this
there are a number of different movements of the joints in
the lower limb. The correct functioning of the movement
patterns of these joints allows a smooth and energy efficient
progression of the body. The relationship between the
movements of the joints of the lower limb is critical. If there
is any deviation in the coordination of these patterns the
energy cost of walking may increase and the shock absorp-
tion at impact and propulsion may not be as effective.
How to find segment angles and
joint angles
Segment angles are defined as the angle of body segments
away from the vertical axis (Figure 15.2). Segment angles
can be calculated by knowing the co-ordinates of the proxi-
mal and distal ends of a body segment in a particular plane.
The angle can then be found using trigonometry.
A joint angle is defined as the angle between the line of
the proximal and distal segments of a joint. Figure 15.3
shows the hip, knee and ankle joint angles (α,β,γ). The
angle
Y
X
Figure 15.2  The segment angle.
ankle joint angle is defined by the foot with respect to a
line 90 degrees to the tibia, with dorsiflexion defined as a
positive angle and plantar flexion as a negative angle. The
knee joint angle is defined by the long axis of the tibia
with respect to the long axis of the femur, with full exten-
sion defined as zero degrees and movement into flexion
being positive. The hip joint angle is defined by the long
axis of the femur with respect to the pelvis, with flexion
defined as positive and extension negative.
Joint angles which are commonly reported include:
ankle plantar-dorsiflexion, foot rotation, knee flexion/
extension, knee valgus/varus, knee rotation, hip flexion/

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 Tidy’s physiotherapy

extension, hip abduction/adduction, hip rotation, pelvic

tilt, pelvic obliquity and pelvic rotation. Although all these
movement patterns are of interest, only major movement
patterns of the lower limb are covered within this chapter.

α
Motion of the ankle joint
The movement of the ankle joint is of great importance as
it allows shock absorption at heel strike, progression of the
body forwards during the stance phase and is vital in the
‘push off’ or propulsive stage immediately before the toe
leaves the ground. During the swing phase the motion of
the ankle joint allows foot clearance, which can be lacking
in some pathological gait patterns and is generally known
as ‘drop foot’.
The range of motion that occurs in walking varies
β between 20 degrees and 40 degrees, with an average value
of 30 degrees. However, this does not tell us how the
motion of the ankle varies throughout gait. During gait
the ankle has four phases of motion (Figure 15.4).

Phase 1
γ At initial contact, or heel strike, the ankle joint is in a
neutral position; it then plantar flexes to between 3 and 5
Figure 15.3  Joint angle definitions. degrees until foot flat has been achieved. This is some-
times referred to as ‘first rocker’ or ‘first segment’, which
refers to the foot pivoting about the heel or calcaneus.
During this period the dorsiflexor muscles in the anterior

20

15
Dorsiflexion
10
2
Joint angle (degrees)

5
3
0
1 10 20 30 40 50 60 70 80 90 100
-5

-10
Plantar flexion
-15 4
-20
% of gait cycle
-25

Phase 1 Phase 2 Phase 3 Phase 4

Figure 15.4  Ankle movement through the gait cycle.

334

compartment of the foot and ankle are acting eccentrically,
controlling the plantar flexion of the foot. This gives the
effect of a shock absorber and aids smooth weight accept-
ance to the lower limb.
Phase 2
At the position of foot flat the ankle then begins to dorsi-
flex. The foot becomes stationary and the tibia becomes
the moving segment, with dorsiflexion reaching a
maximum of 10 degrees as the tibia moves over the ankle
joint. The time from foot flat to heel lift is referred to as
‘second rocker’ or ‘second segment’, which refers to the
pivot of the motion now being at the ankle joint with
the foot firmly planted on the ground. During this time
the plantar flexor muscles are acting eccentrically to
control the movement of the tibia forwards.
Phase 3
The heel then begins to lift at the beginning of double
support, causing a rapid ankle plantar flexion reaching an
average value of 20 degrees at the end of the stance phase
at toe off. The ankle plantar flexes at a rate of 250 degrees
per second. This rapid movement is associated with power
production. During this propulsive phase of the gait cycle
the plantar flexor muscles in the posterior compartment
of the foot and ankle contract concentrically, pushing the
foot into plantar flexion and propelling the body forwards.
70.0
60.0
50.0
Joint angle (degrees)
40.0
Flexion
30.0
20.0
1 2
10.0
0.0
10 20 30
Phase 1 Phase 2
Figure 15.5  Knee movement through the gait cycle.
Biomechanics Chapter 15
This is referred to as ‘third rocker’ or ‘third segment’ as the
pivot point is now under the metatarsal heads.
Phase 4
During the swing phase the ankle rapidly dorsiflexes (150
degrees per second) to allow the clearance of the foot from
the ground. A neutral position (0 degrees) is reached by
mid-swing, which is maintained during the rest of the
swing phase until the second heel strike. This is referred
to as the ‘fourth segment’. It has been recorded that there
is sometimes a 3–5 degree dorsiflexion during the swing
phase. During this phase the ankle dorsiflexors concentri-
cally contract to provide foot clearance from the ground
and prepare for the next foot strike.
Motion of the knee joint
During gait the knee joint moves in the sagittal, transverse
and coronal planes. However, the majority of the motion
of the knee joint is in the sagittal plane, which involves
the flexion and extension of the knee joint. The flexion
and extension of the knee joint is cyclic and varies between
0 and 70 degrees, although there is some variation in the
exact amount of peak flexion occurring. These differences
may be related to differences in walking speed, subject
individuality and the landmarks selected to designate limb
segment alignments. There are five phases (Figure 15.5).
4
5
3
40 50 60 70 80 90 100
% of gait cycle
Phase 3 Phase 4 Phase 5
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 Tidy’s physiotherapy

Heel strike the propulsive phase of the gait cycle. The knee then con-
tinues to flex in preparation for swing phase, sometimes
At heel strike, or initial contact, the knee should be flexed
referred to as pre-swing.
(Figure 15.5). However, people’s knee posture can vary
between slight hyperextension (–2 degrees) to 10 degrees Phase 4
of flexion, with a mean value of 5 degrees.
Toe off occurs when the knee flexion is approximately 40
Phase 1 degrees, at which time the knee is flexing at a rate of
300–350 degrees per second. This flexion, coupled with
After the initial contact there is a flexion of the knee joint
the ankle dorsiflexion, allows the toe to clear the ground.
to about 20 degrees when the knee is flexed under
During initial-to-mid-swing the knee continues to flex to
maximum weight-bearing load. The knee joint flexes to
a maximum of 65–70 degrees.
absorb the loading at a rate of 150–200 degrees per
second. This occurs at the same time the ankle joint Phase 5
plantar flexes, with a net effect to act as a shock absorber
During late swing, the knee undergoes a rapid extension,
during the loading of the lower limb. During this time the
350–400 degrees per second to prepare for the second heel
knee extensors are acting eccentrically.
strike.
Phase 2
Motion of the hip joint in  
After this first peak of knee flexion the knee joint extends
at a rate of 80–100 degrees per second to almost full exten-
the sagittal plane
sion. This is concerned with a smooth movement of the During walking the leg flexes forward at the hip joint
body over the stance limb. to take a step and then extends until push off. This motion
forms an arc starting at initial contact and finishing at
Phase 3 toe off.
The knee then begins its second flexion phase, which coin- The motion of the hip joint is relatively simple (Figure
cides with the heel lift. During this, the lower limb is in 15.6). Maximum hip flexion occurs during terminal swing
Hip flexion-extension
50

40 Flexion
3
30 1
Joint angle (degrees)

20

10
2
0
10 20 30 40 50 60 70 80 90 100

-10
Extension % of gait cycle
-20

Phase 1 Phase 2 Phase 3

Figure 15.6  Hip movement through the gait cycle.

336
 Biomechanics Chapter 15

(phase 3), this is followed by a slight extension before
initial contact, (phase 1). After initial contact (phase 1)
the hip then extends as the body moves over the limb at
a rate of 150 degrees per second. Maximum hip extension
occurs just after opposite foot strike (phase 2), weight is
then transferred to the forward limb and the trailing limb
begins to flex at the hip. This is the pre-swing period. The
toe leaves the ground at 60% of the gait cycle and the hip
flexes rapidly at a rate of 200 degrees per second. This can
be seen from the slope of the angle against time plot
below, to progress the limb forward and prepare for the
next initial contact (phase 1).
Motion of the pelvis in the coronal
plane (pelvic obliquity)
During the early stance phase the contralateral (swing)
side of the pelvis drops downward in the coronal plane
(Figure 15.7). In order to achieve foot clearance the knee
on the contralateral side undergoes rapid flexion. In
normal gait the peak pelvic obliquity (drop down) occurs
just after opposite toe off, which corresponds to the early
stance phase on the weight-bearing limb.
Pelvic obliquity serves three purposes: to aid shock
absorption, to allow limb length adjustments and to reduce
the vertical excursions of the body (improving efficiency).
To illustrate these points we will consider the gait of an
above-knee amputee. In above-knee amputees the pelvic
obliquity does not always follow the normal pattern
owing to loss of the normal knee joint control. A common
strategy is that of hitching up the contralateral side of the
pelvis to ensure foot clearance. In this way pelvic obliquity
can be used to shorten the effective limb length when
required. However, this increases energy expenditure as it
increases the vertical excursion of the body.
Motion of the pelvis in the
transverse plane (pelvic rotation)
During normal level walking the pelvis rotates about a
vertical axis alternately to the left and to the right (Figure
15.8). This rotation is usually about four degrees on each

10.0

8.0
Up
6.0

4.0
Joint angle (degrees)

2.0

0.0
10 20 30 40 50 60 70 80 90 100
-2.0

-4.0

-6.0 Down

-8.0

-10.0 % of gait cycle

Figure 15.7  Pelvic obliquity.

337
 Tidy’s physiotherapy

8 Rotation forwards
6
4
Joint angle (degrees)

2
0
10 20 30 40 50 60 70 80 90 100
-2
-4
-6
-8 Rotation backwards % of gait cycle
Figure 15.8  Pelvic rotation.

side of this central axis – the peak internal rotation occur- of movement in any particular direction or anatomical
ring at foot strike and the maximal external rotation at plane:
opposite foot strike. This rotation effectively lengthens the change in displacement
limb by increasing the step length and prevents excessive velocity =
time
drop of the body, making the walking pattern more effi-
cient. Pelvic rotation also has the effect of smoothing the
Linear acceleration
vertical excursion of the body and reducing the impact at
foot strike. Acceleration is the rate of change of velocity, i.e. the change
in velocity over a given time:
acceleration = change in velocity/time.
HOW TO FIND LINEAR
DISPLACEMENT, VELOCITY AND
ACCELERATION KINEMATICS OF A REACHING TASK

The above equations can be used to examine the quality of

Linear displacement
Linear displacement refers to the movement of an object
a particular distance in a particular direction. Displace-
ment may be found by multiplying average velocity by
time. The average velocity may be found by adding the
initial and final velocities and dividing by two:
(initial velocity + final velocity)
average velocity =
2
Linear velocity
Linear velocity is the rate of change of displacement, i.e.
the distance covered in a particular time. This is the speed
movement of different tasks. We will consider linear control
by evaluating what information may be gained from the
study of the movement of the hand forwards during a
reaching task, such as reaching to pick up a cup, in a subject
who is pain- and pathology-free and a patient who has a
painful unstable shoulder. The motion of the upper limb
during reaching can be examined by studying the displace-
ment, velocity and acceleration graphs. All of these are
derived from the same displacement data; however, they
all yield significantly different information which may be
used to help us to describe functional aspects of the task.
The process of finding velocity from displacement and
acceleration from velocity is called differentiation.

338
 Biomechanics Chapter 15

Linear displacement of the hand
during reaching with and without
shoulder dysfunction
This graph is drawn from knowing how the linear position
of the hand varies over time. Figure 15.9 shows the hand
starting at a position zero and moving forwards in a reach-
ing motion. The gradient of the curve indicates the velocity
at which the hand is moving throughout the task. Figure
15.10a shows an individual who is pain- and pathology-
free and Figure 15.10b shows an individual with a painful,
unstable shoulder. Both show a similar pattern; however,
Figure 15.9  Motion of the upper limb during reaching.
0.45
0.4
0.35
0.3
Velocity (m/s)
the individual with the painful unstable shoulder appears
to have a less smooth pattern of movement. We are,
however, limited in the measurements we may take from
linear displacement graphs; at best we can find the time
taken to complete the task and the distance reached with
very little information about the performance and quality
of the movement during the task.
Linear velocity of the hand during
reaching with and without  
shoulder dysfunction
The velocity graph is found by measuring the change
in the linear displacement over each successive time inter-
val. The linear velocity graph for the hand of the indi-
vidual who is pain- and pathology-free shows a bell-shaped
curve (Figure 15.11a). Initially, the velocity of the hand is
zero; the hand then accelerates to its maximum velocity at
approximately the mid-point of the reaching movement.
The hand then decelerates as it gets closer to its target; this
takes slightly longer than the acceleration phase to ensure
control and accuracy of hand positioning. The individual
with a painful unstable shoulder (Figure 15.11b) shows a
marked difference when considering the linear velocity
graph. It shows a rapid acceleration then a continuously
varying velocity which is followed by a decrease then an
increase in velocity indicating either an unstable or painful
part of the movement. The peak velocity may be measured
from this graph indicating the level of performance of the
task. The unsmooth nature of the pattern gives us a further

insight to the control of the task but we cannot measure

0.25
this directly from the linear velocity graph.
0.2
0.15
0.1 Linear acceleration of the hand
0.05 during reaching with and without
0 shoulder dysfunction
0 0.2 0.4 0.6 0.8 1
A Time (s) The acceleration graph is found by measuring the change
in the linear velocity over each successive time interval.
0.45 The individual who is pain- and pathology-free (Figure
0.4 15.12a) shows an initial acceleration peak early in the
0.35 movement. The acceleration then decreases to zero as the
Velocity (m/s)

0.3 hand reaches its maximum velocity. The hand then goes
0.25 into a deceleration phase as it reaches its target. The peak
0.2 deceleration is lower than the acceleration phase, and the
deceleration phase lasts for a longer period of time, as
0.15
shown with the velocity curve; again, this is to ensure
0.1 controlled accuracy of positioning the hand at the target.
0.05 The individual with a painful unstable shoulder (Figure
0 15.12b) shows a marked difference when considering the
0 0.2 0.4 0.6 0.8 1
linear acceleration graph – it shows a rapidly changing
B Time (s)
graph indicating a lack of smooth controlled movement
Figure 15.10  Displacement versus time of a reaching task: with no clear acceleration and deceleration period. This
(a) pain- and pathology-free; (b) with a shoulder dysfunction. lack of smoothness tells us important information about

339
 Tidy’s physiotherapy

1 a lack of control which could be owing to poor articula-

0.8 tion at the shoulder or poor neuromotor control.
Velocity (m/s)

0.6 It is important to reiterate that the information presented

0.4 for displacement, velocity and acceleration comes from the
same original data from the cumulative displacement and
0.2
time. It is also important to realise that each of these graphs
0
tells us different information about the amount of move-
-0.02 0.2 0.4 0.6 0.8 1
ment, the performance of movement and the control of
A Time (s)
movement during the task. Movement control strategies
0.4
may vary depending on various factors such as task, object,
0.35 individual or cognitive constraints.
0.3
Velocity (m/s)

0.25
0.2
HOW TO FIND ANGULAR
0.15
0.1
DISPLACEMENT, VELOCITY  
0.05 AND ACCELERATION
0
0.2 0.4 0.6 0.8 1
-0.05 Angular displacement
Time (s)
B
Angular displacement is given the symbol (θ). This refers
Figure 15.11  Velocity versus time of a reaching task: to the movement of an object through an angle. Angular
(a) pain- and pathology-free; (b) with shoulder dysfunction. displacement can be measured in two ways, either in
degrees or in radians. There are 360 degrees in a full circle,
or 2π radians. Pi (π) is the ratio of the circumference of a
circle to its diameter (a ratio that is for all circles) and is
6 very close to 3.1416, so 1 radian is about 57.3 degrees.
5
4
Angular velocity
Acceleration (m/s2)

3
2 Angular velocity is the rate of change of angular displace-
1 ment or the rate at which an angle is covered in a particular
0 time. This is referred to as the angular velocity and is given
-1 0.2 0.4 0.6 0.8 1 the symbol (ω). Angular velocity can be expressed in
-2 degrees per second or radians per second.
-3
-4
A Time (s) Angular acceleration
Angular acceleration is the rate of change of angular veloc-
0.4
ity and is given the symbol (α). As with linear acceleration,
0.35 this relates to the muscles overcoming inertial forces to
either start or stop movement, therefore muscle forces can
0.3
either cause an angular acceleration or deceleration of a
Acceleration (m/s2)

0.25 joint. Angular acceleration can be written in degree/s2 or

0.2 0.4 0.6 0.8 1 radians/s2.
0.2

0.15
KINEMATICS OF THE KNEE  
0.1
DURING WALKING
0.05
Time (s)
B As with the linear movement of the hand during reaching
Figure 15.12  Acceleration versus time of a reaching task: tasks we can use the angular equations of motion to
(a) pain- and pathology-free; (b) with shoulder dysfunction. examine the quality of movement of joints during differ-
ent tasks. We will now consider the movement of the knee
joint in a subject who is pain- and pathology-free and a
patient who has medial compartment knee osteoarthritis.

340

Again, all of these graphs are derived from the same
angular displacement data; however, they all yield differ-
ent information to help us describe the functional per-
formance of the knee.
Knee angular displacement of
normal knee function and medial
compartment knee osteoarthritis
during walking
During normal walking the motion of the knee joint in
the sagittal plane varies between 0 and 70 degrees (Figure
15.13a), although there is some variation in the exact
amount of peak flexion occurring. At heel strike, or initial
contact, the knee is flexed. After the initial contact there is
a controlled increase in knee flexion to about 20 degrees
when the knee is flexed under maximum weight-bearing
load. During this time the knee extensors are acting eccen-
trically. After this first peak of knee flexion the knee joint
extends this in relation to a smooth, eccentrically control-
led movement of the body over the stance limb. The knee
undergoes a rapid flexion in preparation for swing phase,
sometimes referred to as pre-swing. Toe off marks the start
70
Knee flexion
Angle(degrees)
35
0
0.0 50 100
A % gait cycle
70
Knee flexion
Angle(degrees)
35
0 extension velocity is markedly reduced indicating a sub-
0.0 50 100
B % gait cycle
Figure 15.13  Knee angular displacement during walking.
(a) An adult who is pain- and pathology-free. (b) A patient
with medial compartment knee osteoarthritis.
Biomechanics Chapter 15
of swing phase which allows the toe to clear the ground.
During initial-to-mid-swing the knee continues to flex to
a maximum of 65–70°. During late swing, the knee under-
goes a rapid extension to prepare for the second heel
strike.
In the patient with medial compartment knee osteoar-
thritis (Figure 15.13b), the amount of knee flexion attained
during stance phase is significantly lower than that of
normal, which could indicate poor eccentric control or a
pain avoidance mechanism. The knee then re-extends but
not to the same amount as normal – again indicating pain
avoidance or reduced control. Swing phase appears to
follow a normal pattern of movement but with a reduced
amount of knee flexion at mid-swing.
The comparison of the angle against time graphs allows
us to identify the positions of the joint at different stages
during walking. From this we can examine the range of
movement during the different parts of the task; however,
we cannot take any direct measures of performance and
control of movement from these graphs.
Knee angular velocity of normal
knee function and a patient with
medial compartment knee
osteoarthritis during walking
The velocity graph is found by measuring the change in
the angular displacement over each successive time inter-
val, allowing us to show the speed of movement into
flexion or extension during walking. This tells us more
about how the movement is achieved. A flexing angular
velocity is defined as being positive and extension angular
velocity as negative. Such graphs have been used to deter-
mine the performance and control of joints, and have
been used to determine functional deficits in different
pathologies.
During normal walking (Figure 15.14a) the knee flexes
to approximately 200 degrees per second during loading,
which gives a measure of the eccentric control of the knee
during loading. The knee then extends at a rate of approxi-
mately 100 degrees per second, which shows a smooth,
controlled movement over the stance limb as the body
moves forwards. During swing phase the knee flexes and
extends with an angular velocity of approximately 400
degrees per second.
In the patient with medial compartment knee osteoar-
thritis (Figure 15.14b) the knee flexes with a reduced
angular velocity, therefore the eccentric speed and the
control of the knee during loading is reduced. The knee
stantial deficit in the control, or pain avoidance when
moving over the stance limb. Interestingly, during swing
phase the control of the knee flexion extension appears
close to that of normal suggesting that the knee can move
freely when not under load.
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 Tidy’s physiotherapy
400
Angular velocity (degrees/s)
0 1000
-400
0.0 50 100
A % gait cycle
400
Angular velocity (degrees/s)
0
-400
0.0 50 100
B % gait cycle
Figure 15.14  Knee angular velocity during walking. (a) An
adult who is pain- and pathology-free. (b) A patient with
medial compartment knee osteoarthritis.
The comparison of the angular velocity allows us to
take measurements that relate to the eccentric and concen-
tric control of the joint. Therefore, we are not just looking
at what joint angle is attained at different points during
walking but how the joint is controlled between these
points.
Knee angular acceleration of normal
knee function and a patient with
medial compartment knee
osteoarthritis during walking
The acceleration graph is found by measuring the change
in the angular velocity over each successive time interval,
which allows us to determine the smoothness and control
of movement into flexion or extension during walking.
This also yields important information necessary for the
calculation of joint moments, particularly during swing
phase. Acceleration into flexion is referred to as positive
and a deceleration is negative.
During normal walking (Figure 15.15a) the knee shows
a steady pattern of acceleration and deceleration during
342
4000
Angular acceleration (degrees/s2)
-4000
0.0 50 100
A % gait cycle
6000
Angular acceleration (degrees/s2)
4000
3000
0
-3000
-4000
-6000
-8000
0.0 50 100
B % gait cycle
Figure 15.15  Knee angular acceleration during walking
(a) An adult who is pain- and pathology-free. (b) A patient
with medial compartment knee osteoarthritis.
stance and swing phase. The absence of any rapid changes
in acceleration shows that the movement is both smooth
and controlled.
In the patient with medial compartment knee osteoar-
thritis (Figure 15.15b) the knee shows several points with
rapid changes in acceleration during mid-stance, in par-
ticular, as the body moves over the stance limb. This
reflects a deficit in the smoothness and control during this
period. It is also interesting to note a deficit in smooth
movement during swing phase, which had previously
gone undetected, indicating that this movement is not as
smooth as we previously thought.
METHODS OF MOVEMENT ANALYSIS
Methods used for movement analysis vary enormously,
and are widely dependent on clinical conditions, skills,
available facilities and the purpose of the assessment. We
will now consider several methods that can be used to
collect objective data for a variety of different pathological
conditions.
 Biomechanics Chapter 15

Common clinical tools

Often in clinical settings, joint angles are assessed simply
using a hand-held goniometer. There are several types of
goniometer, all giving a crude, but useful, measure of
angles and range of motion. Clinically, the goniometer
allows a quick and useful assessment of static angles.
However, these devices are of little use when measuring
angles dynamically during different movement tasks.
Further information on clinical measurements using
instrumentation such as the goniometer are available in
the handbook A Physiotherapist’s Guide to Clinical Measure-
ment (Fox and Day 2009).
Spatial parameters can be measured in a variety of
simple ways, including putting ink pads on the soles of
the subject’s shoes and walking on paper (Rafferty and Bell
1995), and using marker pens attached to shoes (Gerny
1983). Although very cheap, these systems can require
awkward and time-consuming analysis. Temporal param-
eters can be measured by timing how long it takes an
individual to walk a set distance and counting the number
of steps it took to cover that distance. However, this will
only give average velocity and cadence, and will give no
value to the symmetry of these parameters. This technique
is extremely susceptible to human error. A

Walk mat systems

In the last two decades of the twentieth century advances
in computer technology led to the development of a
number of instrumented walk mat systems. These allow
fast collection of temporal and spatial gait data. Using
a computer also allows easier, less time-consuming
analysis. These systems include apparatus for step length
measurement (Durie and Farley 1980), a system for moni-
toring the position and time of foot contact during
walking (Arenson et al. 1983), using a measuring walkway
B
(Hirokawa and Matsumura 1987), a microcomputer-
based system (Crouse et al. 1987) and a walk mat system
(Al-Majali et al. 1993). Walk mat systems that do not Figure 15.16  GAITRiteTM system and typical output from
require any modifications to the footwear are now com- GAITRiteTM.
mercially available. These offer far less interference with
the gait cycle. One such system is the GAITRiteTM system,
patterns of a running man and in 1901 published The
which uses pressure sensor arrays to determine foot
Human Figure in Motion. Marey, a French physiologist, used
position (Figure 15.16).
a ‘photographic rifle’ to photograph movement of animals
in 1873, and in 1882 and 1885 to record displacements
in human gait to produce the first stick figure of a runner.
Movement analysis systems
In the second half of the twentieth century many
In the late nineteenth century the first motion picture systems capable of automated and semi-automated
cameras recorded patterns of locomotion in both humans computer-aided motion analysis were developed. One of
and animals. In 1877, Muybridge demonstrated, using the first systems to become commercially available was the
photographs, that when a horse is moving at a fast Ariel Performance Analysis System, which required the
trot there is a moment when all of the animal’s hooves are operator to manually identify the location of joint
off the ground and in 1887 published Animal Locomotion. centres or passive markers placed on the body used for
Muybridge later used 24 cameras to study the movement each frame. Since then, the problems of automatic marker

343
 Tidy’s physiotherapy
A
B friction in the bearings of the wheels and axle. This means
Figure 15.17  (a) UCLan’s Movement Analysis Laboratory
in the Allied Health Research Unit. (b) Automatic digitising
using Qualisys Track Manager (QTM).
identification have been at the forefront of the develop-
ment of computer-aided motion analysis. In 1974,
SELSPOT became commercially available, which allowed
automatic tracking of active light-emitting diode (LED)
markers; later OptotrakTM and CODATM used a similar tech-
nique. VICON, a camera based system, became commer-
cially available in 1982. Since then, many systems based
on television-camera technology have been developed,
including the Motion Analysis Corporation system, Elite,
and Oqus by QualisysTM (Figure 15.17).
More recent advances in movement analysis have seen
the development of three-dimensional motion capture
suits, such as the XSens MVNTM system. This system is a
camera-free motion system with a full body configuration
of inertial motion trackers. Such configurations allow
increased flexibility as they do not require a laboratory for
data collection.
UNDERSTANDING FORCES
Forces
Forces make things move, stop things moving or make
things change shape. They can either push or pull. Force
344
is a vector, which simply means it has both direction and
magnitude. All forces thus have two characteristics, mag-
nitude and direction, and both need to be stated in order
to describe the force fully. A good place to start is with the
laws formulated by Sir Isaac Newton. In 1687 Newton
published three simple laws, which together enshrine the
fundamental principles of mechanics.
Newton’s first law
If an object is at rest it will stay at rest. If it is moving with
a constant speed in a straight line it will continue to do
so, as long as no external force acts on it. In other words,
if an object is not experiencing the action of an external
force it will either keep moving or not move at all (Figure
15.18). This law expresses the concept of inertia. The
inertia of a body can be described as being its reluctance
to start moving or stop moving once it has started.
Why not perpetual motion?
Why does a car slow down when rolling on a flat road?
The answer is that there are a number of external forces
that need to be considered, such as wind resistance and
we have to be careful to consider all the forces that are
acting on an object in order to find out how it is going
to move.
Newton’s second law
The rate of change of velocity is directly proportional to
the applied external force acting on the body and takes
place in the direction of the force (Figure 15.19). There-
fore, forces can either cause acceleration or deceleration
of an object. Acceleration is usually defined as being posi-
tive and deceleration as being negative.
If F is the applied force in Newton (N), m is the mass
of the body (kg) and a is the acceleration of the body
(m/s2), then F = ma. Therefore, 1 N is that force which
produces an acceleration of 1 m/s2 when it acts on a mass
of 1 kg.
Key point
In the SI system of units, forces are measured in
Newtons (N).
Newton’s third law
If the box shown in Figure 15.20 exerts a force on the table
top (action), then the table will exert an equal and

At rest Constant velocity
Figure 15.18  Newton’s first law.
Acceleration
F Acceleration owing to gravity
Figure 15.19  Newton’s second law.
Ground reaction force
Weight
Figure 15.20  Newton’s third law.
opposite force on the box (reaction). This does not mean
the forces cancel each other out as they act on two different
objects.
The action of a force on the ground receives an equal
and opposite reaction force. This is known as a ground
reaction force (GRF).
MASS AND WEIGHT
Mass
Mass is the amount of matter an object contains. This will
not change unless the physical properties of the object are
changed, wherever the object is moved.
Weight
Weight is a force. This depends on both the mass of the
object and the acceleration acting on it. Weight is often
interpreted as being the force acting beneath our feet, i.e.
scales measure this force, although they never use the
correct units (they should be Newton).
Biomechanics Chapter 15
Therefore, a good way to lose weight is to stand in a lift
and press the down button. You will lose weight (the ground
reaction force will reduce) as the lift accelerates down­
wards. Unfortunately, when the lift comes to a stop you will
gain weight again as the lift decelerates downwards.
Another example of the difference between mass and
weight is to consider astronauts. When they are in space
they are weightless, but this does not mean they have gone
on an amazing diet, only that there is no acceleration
acting on them. Therefore, weight-watchers should really
be called mass-watchers.
Wherever you are on Earth there is acceleration owing to
gravity acting on you. This does vary a small amount but
the value is generally close to 9.81 m/s2. For the purposes
of rough calculations this is often rounded up to 10 m/s2.
However, to get the best possible accuracy 9.81 m/s2
should be used.
Static equilibrium
The concept of static equilibrium is of great importance in
biomechanics as it allows us to calculate forces that are
unknown.
Newton’s first law tells us that there is no resultant force
acting if the body is at rest, i.e. the forces balance. There-
fore, if an object is at rest, the sum of the forces on the
object, in any direction, must be zero. So, when we resolve
in a horizontal and vertical direction the resultant force
must be zero.
Free-body analysis
Free-body analysis is a technique of looking at and
simplifying a problem. The example below considers
someone pulling a box of weight 40 N along the ground
with a piece of string with a force of 10 N at an angle of
30 degrees to the horizontal (Figure 15.21a). We now
break down what force must be acting on the box and
form a simplified picture of just the box. The forces acting
are the tension in the string, the frictional force, the weight
of the box and the ground reaction force (Figure 15.21b).
Worked example
With reference to Figure 15.22, find the horizontal accel-
eration and the ground reaction force.
Horizontal forces
Horizontal force in string = 10 cos 30° = 8.66
Therefore 8.66 – 2.66 = mass × acceleration
6=4×a
1.5 m/s = a.
Vertical force
Vertical force in string = 10 sin 30 = 5
Ground Reaction Force + 5 – 40 = 0
Ground Reaction Force = 40 – 5 = 35 N.
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 Tidy’s physiotherapy

Tension of force in string

Ground reaction force

Friction force

A B
Weight of box
B Figure 15.23  Postural sway in the anterior-posterior
direction.
Figure 15.21  Free-body analysis.
ground reaction force, but it never happens as easily as
Tension or force of string 10 that with human balancing because of sway.
When standing we have a natural postural sway back-
Ground reaction force
30
wards and forwards (anterior posterior, Figure 15.23)
and from side to side (medial lateral, Figure 15.24). As
Mass = 4kg we sway there are horizontal forces acting, as well as
the vertical force (Figure 15.25). The centre of pressure
2.66
(CoP) is the point at which the force is acting beneath
the feet. During postural sway the centre of pressure
moves forwards, backwards and side to side between the
two feet (Figure 15.26).
40
Figure 15.22  Worked example of Newton’s laws.
Ground reaction forces during  
the gait cycle
Vertical force component
HOW FORCES ACT ON THE BODY
A ground reaction force is made up of three forces
acting in three directions at the centre of pressure:
Ground reaction forces vertical, anterior–posterior and mediolateral. The vertical
component of the ground reaction force can be split into
A ground reaction force is the force that acts on a body as
four sections (refer to Figure 15.27).
a result of the body resting on the ground or hitting the
ground. The study of forces is often referred to as kinetics.
If someone stands on a floor without moving, the Heel strike to first peak
person is exerting a force (the person’s weight) on the Heel strike to first peak is where the foot strikes the ground
floor, but the floor exerts an equal and opposite reaction and the body decelerates downwards, and transfers the
force on the person. That is an example of the simplest loading from the back foot to the front foot during initial

346
 Biomechanics Chapter 15

A B C

Figure 15.24  Postural sway in the medial lateral direction.

Figure 15.26  Movement of the centre of pressure during

Figure 15.25  Postural sway during balance. postural sway.

double support. The first peak should be in the order of
1.2 times the person’s bodyweight.
First peak to trough
Here, in first peak to trough, the knee extends, raising the
body. As the body approaches its highest point it is slowing
down (decelerating the body) in its upward motion. This
reduces the vertical ground reaction force. This has the
same effect as going over a hump-backed bridge in a car:
as you reach the top of the hump you feel very light
because the contact force between you and the seat is
reduced. The trough should be in the order of 0.7 times
the person’s bodyweight.
Trough to second peak
During trough to second peak the centre of mass now falls
as the heel lifts and the foot is pushed down and back into
the ground by the action of muscles in the posterior

347
 Tidy’s physiotherapy

compartment of the ankle joint. Both the deceleration 1.4

downward and propulsion from the foot–ankle complex
cause the second peak. The second peak should be in the 1.2
order of 1.2 times the person’s bodyweight.

Force/bodyweight (N/kg)
1.0

Second peak to toe off 0.8

During second peak to toe off the foot is unloaded as the 0.6
load is transferred to the opposite foot.
0.4
Anterior–posterior force component 0.2
The anterior–posterior component may also be split into
four sections (Figure 15.28). 0
0 10 20 30 40 50 60 70 80 90 100
Percentage stance phase
Clawback
Figure 15.27  Vertical force during normal walking.
Clawback is an initial anterior force that is not always
present during walking. This is caused by the swinging
limb hitting the ground with a backwards velocity thus
causing an anterior reaction force as it decelerates. Claw- 0.25
back is often exaggerated during marching as the swing 0.2
limb is driven back to meet the ground. 0.15
Force/bodyweight (N/kg)

0.1
Heel strike to posterior peak
0.05
After the initial clawback (if present) the heel is in contact
0
with the ground and the body decelerates, causing a pos- 0 10 20 30 40 50 60 70 80 90 100
terior shear force. Imagine you are walking on a thick −0.05
carpet, loading your front foot, and suddenly you are −0.1
transported to an ice rink – your leg would slide forwards −0.15
because the frictional force between the ice and your foot
is very low, whereas the carpet can provide a much larger −0.2
posterior reaction force that stops your leg from slipping −0.25
forwards. The posterior peak should be in the order of 0.2 Percentage stance phase
times the person’s bodyweight. Figure 15.28  Force in the anterior–posterior direction during
normal walking.
Posterior peak to crossover
The posterior component reduces as the body begins to
move over the stance limb, reducing the horizontal com- 0.08
ponent of the resultant ground reaction force.
0.06

Crossover to anterior peak

Force/bodyweight (N/kg)

0.04
During crossover to anterior peak the heel lifts and the
foot is pushed down and back into the ground by 0.02
the action of muscles in the posterior compartment of the
0
ankle joint. This has the effect of producing an anterior 0 10 20 30 40 50 60 70 80 90 100
component of the ground reaction force, which propels
−0.02
the body forwards. The anterior peak should be in the
order of 0.2 times the person’s bodyweight. −0.04

Anterior peak to toe off −0.06

Percentage stance phase
Anterior peak to toe off is the period of terminal double
support where the force is being transferred to the front Figure 15.29  Force in the mediolateral direction during
foot. The anterior force therefore reduces. normal walking.

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 Biomechanics Chapter 15

Mediolateral force component
The mediolateral component may be split into two main
sections (Figure 15.29). Initially, at heel strike, there is a
lateral thrust during loading; during this time the foot is
working as a mobile adaptor. After the initial loading, the
forces push in a medial direction as the body moves over
the stance limb. Small lateral forces are often seen during
the final push-off stage.
The mediolateral forces are the most variable of the
three components and can easily be affected by footwear
and foot orthotics. Normal maximum medial force is
between 0.05 and 0.1 times the person’s bodyweight. The
How to study the measurements taken from
these graphs
For each of these measurements the percentage difference
can be studied between the left and right sides, and
between the subject tested and non-pathological data.
This will not only identify what differences are present in
the walking patterns, but also how big the differences are.
Mid-stance
maximum lateral force should be less than the maximum
medial force.
Pedotti diagrams
The interaction of the vertical and anterior–posterior
forces described above may be shown with a Pedotti
diagram. This shows the magnitude of the resultant
ground reaction force. Pedotti diagrams rely on the infor-
mation provided by force platforms. To construct a Pedotti
diagram we need to know the vertical and horizontal
forces and the positions of the forces beneath the foot in
the plane of interest for each moment in time.
As a subject walks, the forces during the stance phase
move forward from under the heel to the toe, so the posi-
tion of the force moves from posterior to anterior. As we
have seen in the previous section, the vertical and hori-
zontal ground reaction forces are continually changing
during the stance phase, so changing the direction
and magnitude of the resultant ground reaction force
(Figure 15.30).
Figure 15.31 shows the vertical, horizontal and resultant
ground reaction force components being drawn at heel
off. The centre of pressure has moved forwards from the
heel to the forefoot and the new vertical, horizontal and
resultant ground reaction force components are drawn
from the new position. This process is repeated through-
out the stance phase, producing a butterfly-like diagram.

Test yourself

Use the data in Table 15.1 to plot a Pedotti diagram on

graph paper. You should get something similar to that
shown in Figure 15.32.

Heel strike Toe off Table 15.1  Data for the self-assessment task

Figure 15.30  Pedotti diagram during normal walking. Position Anterior–posterior Vertical
(m) force (N) force (N)

0 −8 66

0.04 −155 678

0.08 −180 878

0.12 −54 622

0.16 −13 457

0.2 26 564

0.24 106 889

0.28 180 626

Figure 15.31  Vertical, horizontal and resultant ground 0.32 10 16
reaction forces heel off.

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 Tidy’s physiotherapy

900 To find the total force acting in an anterior–posterior

direction, for example, all the anterior–posterior forces
measured by the load cells will be added to give the total
800
force in that direction.
Force platforms are considered as a basic, but funda-
700 mentally important, tool for gait analysis. The first force
measurements date back as far as the late nineteenth
600 century, when Marey used a wooden frame on rubber
supports. Elftman (1938) used a similar method with
a platform on springs. However, it was not until the
500 advancement of computers and electronic technology
Force (N)

that the readings could be accurately measured. In 1965,

400
300
200
100
0
0 0.8 0.16 0.24 0.32
Centre of pressure (m)
Figure 15.32  Graph from the ‘Test yourself’ task.
METHODS OF FORCE ANALYSIS
Video vector generators
The video vector generator is a piece of equipment that
combines the information from a force platform with a
video image. The resultant force can be superimposed on
top of the video information, giving a picture of the action
of the ground reaction forces (Figure 15.33). This uses
the same information as displayed in the Pedotti diagram,
but also allows the action of the forces to be seen with
respect to the joints of the lower limb giving a visualisa-
tion of the joint moments. This information may be used
to identify pathologies and monitor gross changes due to
treatment. A moment (M) is defined as the magnitude
of force F (how hard you push) multiplied by the
perpendicular distance d of the force away from the pivot
(Figure 15.34).
Force platforms
Force platforms are devices that measure and record
ground reaction forces and their point of application at
the centre of pressure (Figure 15.35).
Peterson and co-workers developed one of the first strain-
gauge force platforms. A plethora of publications now
exists on the applications of such devices in both clinical
research and sports.
Since 1965, forces platforms have undergone consider-
able development by three internationally accepted
manufacturers: Kistler Instruments, AMTI and the Bertec
Corporation. Advances have been in the form of making
the platforms more accurate, increasing sensitivity and
improving portability (Figure 15.36).
Pressure systems
Pressure systems are subtly different to force platforms as
they are only able to measure vertical forces. However,
pressure systems are able to measure the centre of pressure
and the pressure patterns beneath the foot (Figure 15.37),
which may be more clinically relevant for some patient
groups e.g. diabetics with a risk of foot ulceration. Pressure
systems use an array of load sensors, which usually range
from 1 to 4 sensors per cm2 and vary in size from approxi-
mately 40 cm × 36 cm (Figure 15.38) to 2 m × 0.4 m,
although mats with 15.5 sensors per cm2 are now com-
mercially available.
Further developments in the study of foot pressure have
lead to more portable in-shoe pressure analysis systems
which allow the analysis in the clinical setting. One
example of this is Tekscan’s F-Scan system (Figure 15.39).
UNDERSTANDING MOMENTS AND
FORCES
When a force acts on a body some distance away from a
pivot point, a turning effect is set up. Consider opening
and closing a door whereby you are creating sufficient
force to turn the door on its hinges. The force required
to do this action multiplied by the distance away from
the hinges is referred to as the moment (also sometimes
called torque).
Now consider the see-saw in Figure 15.40a. It is clear
that the see-saw will not balance. However, if the 1000 N
force is moved so it is half the distance away from the pivot

350

A D
B E
C F
Figure 15.33  Output of video vector generator showing the ground reaction force at: (a) heel strike; (b) just after heel strike;
(c) at flat foot; (d) at mid-stance; (e) at heel off; (f) just before toe off.
(point of rotation) and the 500 N force is moved twice the
distance as in Figure 15.40b, it will balance.
To solve problems with moments we have to consider
the action of each force in turn. To do this we consider
if it will rotate the object (in this case a see-saw) in a
clockwise or anticlockwise direction. If it is in a clockwise
direction it is considered to be in a positive direction and
if it is anticlockwise it is considered to be in a negative
direction (these are arbitrary choices). Therefore, the
1000 N force will try and turn the see-saw clockwise
and the 500 N force will try and turn the see-saw
anticlockwise.
If the see-saw balances then the sum of the clockwise
turning effects and anticlockwise turning effects must be
Biomechanics Chapter 15
zero. If we say that anticlockwise moments are negative
and clockwise ones are positive, then:
Sum of the Moments = −(1000 × 1) + (500 × 2)
Sum of the Moments = −(1000) + (1000) = 0
i.e. If the sum of the moments on the see-saw is zero then
the see-saw will balance.
Although there seems to be little effect when we con-
sider the see-saw vertically, we have a weight on each side
giving a total weight (force) of 500 + 1000 = 1500 N
downwards. From Newton’s third law we know that there
must be an equal and opposite reaction force at the
pivot of 1500 N acting up on to the pivot of the see-saw
(Figure 15.40c).
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 Force F
Figure 15.37  Pressure patterns beneath the foot.

Figure 15.34  The moment about the ankle joint.

Figure 15.38  Pressure Mat System (FMat Tekscan Inc., South

Boston, MA, USA).

Figure 15.35  A force platform.

Figure 15.39  In-shoe Pressure Measuring System (F-Scan,

Tekscan Inc., South Boston, MA, USA).
B

Figure 15.36  AMTI and Kistler Force platforms.

 Biomechanics Chapter 15

500 N 1000 N

1m 2m

500 N 1000 N

2m 1m

500 N 1000 N

2m 1m

C 1500 N
Figure 15.40  (a) Unbalanced see-saw. (b) Balanced see-saw. (c) Pivot reaction force.

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 Tidy’s physiotherapy
x Ø
Q
Resolved
weight
Weight of forearm
Figure 15.41  Moments in the upper limb using method 1.
HOW FORCES AND MOMENTS ACT
ON THE BODY
Forces and moments acting on the body can be found in
the same way as finding moments acting on a see-saw, as
in the preceding section. Therefore, all we need to know
is the forces acting about a joint and the distances at which
they act from the joint. This is often referred to as inverse
dynamics.
However, forces seldom act at 90 degrees to body seg-
ments. Therefore, we invariably need to resolve the forces
first. There are two methods we can use:
• method 1 – the component of force at 90 degrees to
the body segment;
• method 2 – the horizontal and vertical components
of the force relative to the ground.
Student’s note
This author’s preference is to use the component of force
at 90 degrees to the body segment for upper limb and
upper body (trunk) problems, and the horizontal and
vertical components of the force relative to the ground for
lower limb problems which involve ground reaction forces.
354
Resultant Vertical
component
Horizontal component
Figure 15.42  Moments in the lower limb using method 2.
How to find moments in  
the upper limb
Figure 15.41 shows the weight of the forearm acting
straight down. This will produce an extending moment
about the elbow.
Resolving the force
For this we will use method 1 as the weight of the forearm
is not acting perpendicular to the forearm so we cannot
use it to find the moment. However, if we find the com-
ponent of the weight acting perpendicular to the forearm
then we can.
The component acting perpendicular to the forearm =
weight of the forearm × cos Θ.
Moments about the elbow
The component of the weight is acting a perpendicular
distance of x away from the elbow. Therefore:
Moment about the elbow = weight of the forearm
× cos Q × x.
How to find moments in  
the lower limb
Figure 15.42 shows the resultant ground reaction force
seen at foot flat in a normal subject. The resultant force
can be broken up into two separate components, one in
the vertical direction and the other in the horizontal
direction.

Musc
Rotary component
le forc
e
A
Stabilising
component
mg
Figure 15.43  Components of muscle force.
If we consider the moments about the knee using
method 2, we can find out the effects of both the vertical
and horizontal components of the resultant ground reac-
tion force about the knee.
Resolving the forces
Vertical component = Resultant × sinQ
Horizontal component = Resultant × cos Q .
Moments about the knee
To find the moment about the knee we are going to con-
sider each of these forces separately.
• The horizontal force (resultant × cos Θ) is passing
a perpendicular distance y below the knee. This
force will try to turn the knee in a clockwise
direction.
• The vertical force (resultant x sin Θ) is passing a
perpendicular distance x in front of the knee. This
force will try to turn the knee in an anticlockwise
direction.
If we say all moments going clockwise are positive and
those going anticlockwise are negative, then moments
about the knee may be written as:
Moment about the knee = Resultant × cos Q × y
− Resultant × sin Q × x.
How to find muscle and joint forces
Students without a mathematics background should not
become too worried, as this section uses exactly the same
principles dealt with in previous ones.
Biomechanics Chapter 15
A
Horizontal
joint force Vertical
joint force
mg
Figure 15.44  Components of joint force.
Muscle forces may be considered in the same way as
balancing forces on a see-saw and joint forces may be
considered in the same way as the force at the pivot in the
middle of the see-saw.
Muscle forces
One way to calculate the moment owing to a force inclined
at an angle is to break the force up into two perpendicular
components. This is usually necessary in biomechanics
calculations where the muscle acts at an angle to a body
segment, as in the example in Figure 15.43. The muscle
force has components along and perpendicular to the axis
of the arm.
• The rotary component is the force that tries to turn
the body segment around the proximal joint
(e.g. flexing or extending the elbow joint) and
balances the external moments acting on the body
segment.
Rotary component = muscle force × sin A
• The stabilising component is the force that acts along
the body segment (e.g. the forearm) forcing into, or
pulling out of, the joint.
Stabilising component = muscle force × cos A
The stabilising component acts through the pivot and
has zero moment; the rotary component will produce a
moment about the proximal joint.
Joint forces
To find the joint force we first need to think back to the
see-saw, where the force at the pivot was equal to the sum
of the two forces acting downwards. We shall adopt the
same technique here (Figure 15.44).
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 Tidy’s physiotherapy

Firstly, we need to find all the forces acting in a

vertical direction (including the vertical component of
the muscle force). The only force we will not know is the
vertical force at the joint. The sum of all these forces must
be zero.
Secondly, we need to find all the forces acting in a hori-
zontal direction (including the horizontal component of
the muscle force). The only force we will not know is the
horizontal force at the joint. The sum of all these forces
must also be zero.
Ao

Worked example 1: How to find

muscle and joint forces in the   Weight of
d1 forearm
upper limb
Consider the turning moments about the elbow joint
while holding a weight or, more correctly, a mass of 5 kg
(Figure 15.45). The 5 kg mass will produce a force, or d2
Weight
weight, of 49.05 N and the forearm and hand will produce
a force, or weight, of 25 N. If we know the distance d1 from Figure 15.45  Muscle and joint forces in the upper limb for
the elbow joint to the centre of mass of the forearm and worked example 1.
hand is 0.15 m, and the distance d2 from the elbow joint
to the ‘weight’ is 0.4 m then we can find the moments
about the elbow.

Finding the moment about the elbow joint

Moment = force × perpendicular distance. mf sin 80

Therefore:
Moments about the elbow joint
= (weight of forearm × d1 )
80º
+ (weight × d 2 ) Horizontal
Moments about the elbow joint joint force

= (25 × 0.15) + (49.05 × 0.4)
Vertical mf cos 80 Weight of
Moments about the elbow joint = 3.75 + 19.62 joint force forearm

= 23.37 Nm.

Finding the force in the muscle

Weight
Assume that the muscle is inclined to the forearm at 80
degrees (angle A) and the muscle insertion point is 0.04 m Figure 15.46  Resolving the horizontal and vertical forces.
away from the elbow joint (Figure 15.46).
The muscle must provide an equal and opposite
moment to support the weight of the arm and the weight. component, i.e. the muscle must provide an equal and
However, the muscle is inclined to the forearm so the opposite moment to:
muscle force needs to be resolved so that it is perpendicu- Moments about the elbow joint = 23.37 Nm
lar to the distance from the elbow joint. Therefore:
If the muscle force is given the symbol mf so the vertical mf × sin 80° × 0.04 = 23.37
component (or rotary component) of it will be mf sin 80°.
As the muscle produces an equal and opposite moment, mf = 23.37/(sin 80° × 0.04)
the clockwise component must equal the anticlockwise mf = 593.3 N

356
 Biomechanics Chapter 15

Therefore, the force in the biceps when holding a 5 kg Horizontal joint force − mf cos80° = 0
mass is 593.3 N. To put this into context this is the body Horizontal joint force − 593.3 cos 80° = 0
weight of someone with a mass of 60.5 kg. This highlights
that the amount of force on the muscles and tendons Horizontal joint force = 593.3 cos 80°
is often considerable greater than we would, perhaps, Horizontal force = 103 N
imagine.

Finding the joint force

Vertical forces
In the problem above the vertical forces include: mf sin
80° (584.3 N), weight (49.05 N), weight of the forearm
(25 N) and the vertical joint force (Figure 15.46).
If the force is acting up we will call it positive, if it is
acting down we will call it negative. Therefore:
mf sin80° − weight − weight of the forearm
− vertical joint force = 0
584.3 − 49.05 − 25 − vertical joint force = 0
584.3 − 49.05 − 25 = vertical joint force
510.25 N = vertical joint force
Resultant joint force
There is one last step. What we want to find is the total
effect on the joint, or the resultant joint force. This can be
found simply using Pythagoras:
510.252 + 1032 = R2
520.5 = R = resultant joint force
As with the muscle forces the joint and ligament forces
are also greater than we would imagine. This also helps to
explain why ligaments and bone, which are immensely
strong, are often damaged, and why it is also very impor-
tant to consider these forces during rehabilitation to avoid
overloading these structures.

Horizontal forces
The horizontal forces in this problem are easier; the only Worked example 2: How to find
forces which will have a horizontal component are the
moments in the lower limb
muscle force and the joint force. If the force is acting to
the right we will call it positive, if it is acting to the left we Figure 15.47 shows the ground reaction force acting at
will call it negative. heel strike. The point of application of the ground reaction

0.25 m

950 N
0.03 m
0.85 m

0.40 m

0.1 m
82º

Figure 15.47  Joint moments in the lower limb during walking.

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 Tidy’s physiotherapy

force, the position of the ankle, knee and hip joints are Pivot
known. To determine the effect on the lower limb we need
to calculate the moments produced by the ground reaction
force about (i) the ankle joint, (ii) the knee joint and (iii)

0.1 m
the hip joint. The ground reaction force, 950 N is acting
at 82 degrees to the horizontal.

132.2 N
Resolving
Figure 15.48  Moments about the ankle.
Horizontal ground reaction force = 950 × cos 82
Vertical ground reaction force = 950 × sin 82
Horizontal ground reaction force = 132.2 N Pivot
Vertical ground reaction force = 940.75 N 940.75 N

0.4 m
Once the vertical and horizontal forces have been found
we can now consider the action of each component about 0.03 m
each joint separately.
132.2 N
Pivot
Moments about the ankle (Figure 15.48) Figure 15.49  Moments about the knee.
The vertical component of the ground reaction force acts
straight through the joint; therefore, this will not produce
a moment. The horizontal component acts to the right Pivot
and below the ankle. 940.75 N

Moment about the ankle = 940.75 × 0 + 132.2 × 0.1

0.85 m
= 13.2 Nm
0.25 m
Moments about the knee (Figure 15.49)
132.2 N
The vertical component of the ground reaction force acts Pivot
in front of the knee joint. The horizontal component acts Figure 15.50  Moments about the hip.
to the right and below the knee.
Moment about the knee = −940.75 × 0.03 + 132.2 × 0.4

= 24.66 Nm • The moment about the hip joint is a flexing
moment; therefore, the muscles in the posterior
Moments about the hip (Figure 15.50) compartment of the hip joint must be active (hip
extensors).
The vertical component of the ground reaction force acts
in front of the hip joint. The horizontal component acts
to the right and below the hip. Worked example 3: How to find
muscle and joint forces on the base
Mhip = −940.75 × 0.25 + 132.2 × 0.85 = −122.82 Nm
of the spine
A person lifts a weight of 600 N, as shown in Figure
What are the effects of these moments on 15.51.
the muscles? • Mass of trunk = 52.5 kg
• The moment about the ankle joint is a plantar • Mass of head = 8.5 kg
flexing moment; therefore, the muscles in the • Mass of upper arms = 5.8 kg
anterior compartment of the ankle joint must be • Mass of forearm = 3.4 kg.
active (dorsiflexors). (i) If the centre of mass of the trunk, arms and
• The moment about the knee joint is a flexing head is a horizontal distance of 0.2 m from
moment; therefore, the muscles in the anterior L5–S1 (the base of the spine) and the weights
compartment of the knee joint must be active (knee being lifted are a horizontal distance of 0.42 m
extensors). from L5–S1, find the moment about L5–S1.

358

0.2m
0.42m
mg
A B
Figure 15.51  Muscle and joint forces on the spine.
(ii) If this moment were supported entirely by the
muscle E acting 0.07 m away from L5–S1, what
would be the force in the muscle?
(iii)  Find the resultant force at L5–S1 if the force E
is acting at 40 degrees to the vertical.
Solution
(i) M = 600 × 0.42 + 702 × 0.2 = 392.4 Nm.
(ii) 392.4 Nm = E × 0.07
392.4 / 0.07 = E
5606 N = E
(iii) Force E is acting at an angle to vertical and
horizontal, so we find the vertical and
horizontal component by resolving:
Ev = 5606 × cos 40 = 4294 N
Eh = 5606 × sin 40 = 3603 N
Total force vertical = 4294 + 600 + 702 = 5596 N
Total force horizontal = 3603 N
Resultant = sq root (55962 + 36032)
Resultant = 6655 N.
MOMENTS ABOUT THE ANKLE KNEE
AND HIP JOINTS DURING NORMAL
WALKING
We have previously considered the movement and ground
reaction forces during the gait cycle. We will now consider
the effects of the position of the ground reaction force in
relation to the ankle, knee and hip joints.
Biomechanics Chapter 15
E
mg
Typical ankle moments during
normal gait
At heel strike the ground reaction force passes very close
to the ankle joint centre, therefore producing a very small
moment. In some cases this will be behind the ankle joint
giving rise to a plantar flexion moment. After heel strike
the ground reaction force moves in front of the ankle joint
producing a dorsiflexion moment. This increases as the
force moves under the metatarsal heads and the force
increases during push off (Figure 15.52).
Typical knee moments during
normal gait
At heel strike the ground reaction force initially passes
anterior to the knee joint, giving rise to an extension
moment. The ground reaction force then passes quickly
behind the knee joint causing a flexion moment. After
mid-stance the force passes in front of the knee again until
toe off. During swing phase the knee also has significant
moments owing to the acceleration and deceleration of
the foot and tibia (Figure 15.53).
Typical hip moments during  
normal gait
At heel strike the ground reaction force passes quite far
anterior to the hip joint producing a peak flexion moment.
After heel strike the ground reaction force still passes ante-
rior to the hip; however, the distance from the force to the
hip reduces. After mid-stance the force passes posterior to
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 Tidy’s physiotherapy

1.2 an object is lifted from the floor to the top of a table, work
is done in overcoming the downward force owing to
Moment (Nm/kg)

Dorsiflexion
gravity. However, if a constantly acting force does not
0.4 produce motion, no work is performed.

Plantar flexion Key point

–0.4
0.0 50.0 100.0
Gait cycle (%) • Holding a book steadily at arm’s length does not
involve any work, irrespective of the effort required,
Figure 15.52  Typical ankle moments during normal gait.
because there is no movement of the applied force.
0.4 • The units of work are newton × metres or joules (J).
Extension
Moment (Nm/kg)

–0.2
Linear power
Flexion
Power is the rate of performing work or transferring energy.
Therefore, power measures how quickly the workis done.
–0.8 Suppose a person pushes a box from one end of the
0.0 50.0 100.0
room to the other in ten seconds, then pushes the box
Percentage gait cycle
back to its original position in five seconds. In each trip
Figure 15.53  Typical sagittal knee moments during normal across the room, the force applied and the distance the
gait. box is moved is the same, so the work done in each case
is the same. But the second time the box is pushed across
1.0 the room, the person has to produce more power than in
the first trip because the same amount of work is done in
Moment (Nm/kg)

Flexion
five seconds rather than ten.
0.0
Extension Power = work done/time taken

–1.0
0.0 50.0 100.0 Key point
Percentage gait cycle
The units of power are joules per second (J/s) or watts
Figure 15.54  Typical sagittal hip moments during normal (W).
gait.

the hip giving rise to an extension moment. As with the

knee there are significant moments during swing phase Linear energy
owing to the acceleration and deceleration of the lower While work is done on a body, there is a transfer of energy
limb (Figure 15.54). to the body, and so work can be said to be ‘energy in
transit’.

HOW TO FIND LINEAR WORK, Key point

ENERGY AND POWER
Linear work
Work is a product of a force applied to a body and the
displacement of the body in the direction of the applied
force (Figure 15.55).
Work = force × displacement (W = Fs).
Linear work does not refer to the muscular or mental
effort. Work is basically a force overcoming a resistance
and moving an object through a distance. If, for example,
Energy has the same units as work (joules) as the work
done produces a change in energy.
Energy is the capacity of matter to perform work as the
result of its motion or its position in relation to forces
acting on it. Energy related to position is known as poten-
tial energy and energy associated with motion is known
as kinetic energy. A swinging pendulum has maximum
potential energy at the terminal points; at all intermediate
positions it has both kinetic and potential energy in
varying proportions.

360
 Biomechanics Chapter 15

Conservation of energy The length of the arc is affected by the radius of the arc
and the angle moved through.
Energy can be transformed but it cannot be created or
destroyed. In the process of transformation either kinetic Length of an arc = radius × angular displacement
or potential energy may be lost or gained, but the sum Length of an arc = rQ.
total of the two always remains the same.
Note: the angular displacement must be measured in
Potential energy radians (rads):
This is stored energy possessed by a system as a result of 1 radian = 57.3°
the relative positions of the components of that system. Work = Fs
For example, if a ball is held above the ground, the system
Angular work = FrQ.
comprising the ball and the earth has a certain amount of
potential energy; lifting the ball higher increases the
However:
amount of potential energy the system possesses. This is
expressed mathematically as PE = mgh (mass x gravity × Force × r = moment (M)
height).
Work is needed to lift the ball up, giving the system Therefore:
potential energy. It takes effort to lift a ball off the ground.
The amount of potential energy a system possesses is equal Work = moment ( M) × Q
to the work done on the system.
Potential energy also can be transformed into other
forms of energy. For example, when a ball is held above Angular power
the ground and released, the potential energy is trans-
formed into kinetic energy. Work done
Power =
Time taken
Kinetic energy Force × Θ × r
Power =
This is energy possessed by an object resulting from the t
motion of that object. The magnitude of the kinetic energy
depends on both the mass and the speed of the object or
according to the equation KE = 12 mv2.
Moment ( M) × t
Power =
Time taken
M×Θ
HOW TO FIND ANGULAR WORK   Power =
t
AND POWER
However:
Angular work Q /t = ω (angular velocity )
Work = force × distance moved so:
The distance the force is moved is not in a straight line as Power = Mω
with linear work, but in an arc. To find the angular work
the length of the arc must first be found. ω is in Radian/s (rad/s)

Force (F )
Work done = Force (F )  distance (s) Key:
Friction
Friction force
Pulling force (F )
Work done
Distance (s)
Figure 15.55  Linear work.

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 Tidy’s physiotherapy
JOINT POWER DURING   the involvement of the knee during push off at 50–60%
NORMAL WALKING
The results below are found by combining the joint
moments (M) and joint angular velocities (ω). Positive
values show power generation and negative values show
power absorption. It is also sometimes beneficial to
consider where the muscle action is either concentric or
eccentric. Concentric activity is associated with power gen-
eration, whereas eccentric activity is associated with power
absorption. However, these graphs can be hard to interpret
if you consider whether the moments are trying to flex or
extend, and what movements are occurring at each time.
The examples below consider the power absorption and
generation of the ankle, knee and hip joints during
walking. Power absorption (eccentric activity) is shown
as negative and power generation (concentric activity) is
positive.
Ankle power
If the ankle has a dorsiflexion velocity and the moment is
dorsiflexing about the ankle joint then the posterior
muscles must be working eccentrically and absorbing
power. If the ankle has a plantar flexion velocity and a
dorsiflexion moment then the posterior muscles must be
working concentrically and therefore generating power.
At heel strike there is a plantar flexion moment and
angular velocity, therefore at heel strike there is eccentric
power absorption from the dorsiflexors. This is followed
by an eccentric power absorption by the plantar flexors as
the body moves forwards over the foot. During push off
there is a dorsiflexion moment and a plantar flexion veloc-
ity, therefore power is generated by concentric activity of
the plantar flexors (Figure 15.56).
Knee power
At heel strike the knee shows power generation owing to
the ground reaction force being in front of the knee there-
fore producing an extension moment while the knee is
flexing. This initial power generation or concentric con-
traction of the hamstrings ensures that the knee does,
indeed, flex at heel strike, rather than moving into a hyper-
extended position. After this point the ground reaction
force falls behind the knee creating a flexion moment
while the knee is flexing, therefore the quadriceps will be
working eccentrically to act as a shock absorber. The knee
then shows power generation at approximately 20% of the
gait cycle. At this point, the ground reaction force is behind
the knee and this therefore relates to the quadriceps acting
concentrically, pulling the femur over the tibia. As the
knee extends the ground reaction force passes through the
knee joint producing on moment and therefore little, or
362
no, power is generated or absorbed. It is interesting to note
of the gait cycle. During this time the ground reaction force
falls behind the knee creating a flexion moment but at this
time the knee is flexing and therefore power is being
absorbed, not generated. The knee, therefore, has little or
no involvement in the power production during push off
(Figure 15.57).
Hip power
At heel strike the hip shows power absorption at heel
strike owing to the hip having a small period of flexion
velocity coupled with a flexion moment. The hip then
extends to start to move the body over the stance limb
while the moment is still trying to flex the hip; this is
achieved by power generation by the hip extensors. At
approximately 25% of the gait cycle the moment passes
behind the hip changing from a flexion moment to an
extension moment; however, the hip is still extending.
This relates to power absorption, or eccentric control, of
the hip flexors as the body moves over the stance limb.
After 50% of the gait cycle the hip reaches its maximum
extended position. After this point there is a rapid power
generation during push off. This power generation is a
result of the ground reaction force creating an extension
moment while the hip changes from a flexing angular
velocity to an extending angular velocity and there­
fore contributes to power production during push off
(Figure 15.58).
STRENGTH TESTING AND TRAINING
So far in this chapter we have been looking at moments,
muscle forces and joint forces. However, one way in which
we often talk about muscle and joint performance is
strength. But what exactly is strength? The dictionary tells
us that strength is the capacity for exertion or endurance
or the power to resist force. However, a better way of think-
ing about muscle strength is the amount of force a particu-
lar muscle or muscle group can produce. When evaluating
muscle strength, however, the measures taken do not
directly measure the actual strength of the muscle or
muscle group. What is usually recorded is the effective
moment being produced by the muscle. This is because
muscle forces are hard to measure as we require informa-
tion about the position of muscle, position of the body
segment, muscle insertion points and the line of pull of
the muscle – all of which will be constantly changing
during dynamic activities.
Most measures taken in the clinical setting do not go as
far as to estimate actual muscle forces. However, there
are a number of methods of indirect evaluation. Indirect
evaluation of the force produced by a muscle can,
 Biomechanics Chapter 15

2.5
Power (W/kg)

Generation
0.8

Absorption
–1.0
0.0 50.0 100.0
% gait cycle
Figure 15.56  Typical ankle power during normal gait.

1.3
Generation
Power (W/kg)

–0.2
Absorption

–1.7
0.0 50.0 100.0

% gait cycle
Figure 15.57  Typical knee power during normal gait.

1.0

Generation
Power (W/kg)

0.0

Absorption

–1.0
0.0 50.0 100.0

% gait cycle
Figure 15.58  Typical hip power during normal gait.

363
 Tidy’s physiotherapy
however, be influenced by a number of factors. The fol-
lowing section will consider the different permutations
of these factors when considering upper limb muscle
strength.
These factors include:
• the body segment inclination;
• the position and size of the applied load;
• muscle insertion points;
• angle of muscle pull;
• type of contraction;
• speed of contraction.
Changing the effective moment
caused by the body segment
inclination
The inclination of body segments can have a very large
effect on joint moments. The effect of the weight of the
forearm in the three positions shown is very different
(Figure 15.59). The maximum moment about the elbow
is when the forearm is level, when the forearm is inclined
either up or down the moment reduces, and when the
forearm is vertical there will be no moment about the
elbow at all as the entire weight of the segment will be
acting through the joint. It is also important to note the
direction of the ‘stabilising’ component that acts along the
forearm. When the forearm is angled down the compo-
nent acting along the forearm will try to pull the forearm
away from the upper arm, whereas with the forearm
angled up the forearm is pushed into the upper arm. This
will have the effect of reducing and increasing the joint
force at the elbow respectively.
mg
mg
a) Forearm angled down b) Forearm angled
Figure 15.59  Effective moment caused by the weight of the limb.
364
The position and size of  
the applied load
The position and size of the load applied has an important
effect on the moment about the elbow, and will, in turn,
have a significant effect on the muscle and joint forces.
When assessing muscle strength both these factors should
be measured and taken into account. If you position a
load at the end of a subject’s arm to see if he/she can
support it, the moment will depend on the size of the load
and the subject’s limb length (Figure 15.60).
Both the size of the load and the subject’s limb length
need to be considered when assessing an individual’s
muscle performance or strength. For example, if two
individuals of different heights and therefore different
tibial (shank) lengths conducted the same leg raise activity
with the same loads the shorter of the two would, in fact,
use less muscle force (strength) to lift the same load,
assuming the muscle insertion points were not signifi-
cantly different.
Muscle insertion points
Different muscles will have different insertion points. The
position of these insertion points will have a large effect
on the muscle force required to support a given turning
moment. Two examples are shown in Figure 15.61. In
Figure 15.61a the muscle insertion point is close to the
elbow joint, while in Figure 15.61b the muscle insertion
point is much further away. For a particular load there will
be a larger force in the muscle if its insertion point is close
to the joint. Conversely, if there is a maximum force that
a muscle group can cope with then larger loads will be
mg
b) Forearm horizontal
 Biomechanics Chapter 15

d d

mg mg

mg Figure 15.60  Position and size of the applied load.

Muscle force Muscle force

d d

a) Muscle insertion point close b) Muscle insertion point further

Figure 15.61  Position and size of the applied load to the joint.

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 Tidy’s physiotherapy
Figure 15.62  Effect of the angle of muscle pull.
able to be carried with the insertion point further away
from the joint.
This leads us to an interesting point when we consider
weight lifters. Is a weight lifter able to lift the larger load
because he or she can support larger muscle forces or is
this owing to a difference in the muscle insertion points?
If this is the case are we actually assessing something dif-
ferent from strength (the force in the muscle) with the task?
The effect of the angle of   muscle contraction are isometric, concentric and eccentric.
muscle pull
As the body segment moves relative to the ground, so
does the angle of the muscle relative to the body segment.
Consider different inclinations of the body segment, but
instead of thinking about the moment owing to the
weight, think about the line of action of the force in rela-
tion to the forearm. The maximum moment that the
muscle can produce is when the elbow is at 90 degrees
as this makes an approximately 90 degree angle between
the muscle and the body segment, and therefore pro-
duces the greatest rotary component from the muscle
force. As the elbow joint is moved away from this posi-
tion, either flexed or extended, the moment that the
muscle can produce is reduced as the rotary component
of the muscle force acting at 90 degrees to the forearm is
reduced. When the forearm is vertical with the elbow
fully extended the muscle would find it much harder to
produce a moment as the rotary component will be at its
smallest. It is also interesting to note the direction of the
‘stabilising’ component of the muscle force when the
elbow is flexed. This appears to be pulling the forearm
away from the joint and will not provide a compressive
366
stabilising force into the joint; however, in this position
the rotary component will be providing a compressive
force into the joint. In reality, we will also have a
co-contraction from the extensor muscles to stabilise the
elbow joint (Figure 15.62).
Type of muscle contraction
The type of muscle contraction affects the resistance that
can be controlled, held or overcome. The three types of
Isometric contractions are stabilising contractions where
the muscle length remains virtually constant. Concentric
contractions are where the muscle shortens during the
activity. These are generally the weakest muscle contrac-
tions, requiring more motor unit recruitment than isomet-
ric and eccentric for a particular load. Eccentric contractions
are where the muscle lengthens during the activity. These
are generally the strongest muscle contractions, requiring
less recruitment than isometric and concentric for a par-
ticular load.
The effect of the speed of
contraction
There are three ways of classifying speed during exercises:
isotonic, isokinetic and isometric. Isotonic is when a con-
stant load is applied but the angular velocity of the move-
ment may change, allowing an infinite variation in the rate
of contraction of a muscle. Although this is closest to real
life muscle and joint function the changing in speed con-
tinually affects the amount of force that a muscle can
produce and makes the exact muscle function quite hard
 Biomechanics Chapter 15

A B

Figure 15.63  JTech Commander Powertrack II.

to assess. Isokinetic is when the velocity or angular velocity

of the movement is kept constant, but the load may be
varied. This setting of the speed of working helps improve
our assessment of muscle performance, but the speed or
velocity of the joints are being restricted to only one set
speed at any one time. Isometric relates to the force varying
but the joint is held in a static position, therefore muscle
length remains the same as no movement occurs. This tells
us what static moment may be supported; however, it does
not necessarily relate to the moments that can be pro-
duced or supported dynamically.

Methods of objective assessment

One method of improving the measurements taken in
clinical assessment is using a handheld dynamometer.
One example of a dynamometer is the Jtech medical Com-
mander Powertrack II, which is a force gauge that has
been used to assess the muscle strength component of the
constant score to evaluate shoulder function (Figure
15.63). It does have the drawback of assessing isometrics
and not dynamic tasks, and care must still be taken in the Figure 15.64  Isokinetic machine.
position of the device on the body segments to ensure
repeatable and useful measurements.
Another method is using an isokinetics dynamometer, and isometric moments (commonly referred to as torque
which allows for a standardised assessment by controlling, in isokinetics), and concentric and eccentric power to
or pre-setting the angular velocity and measuring the be found separately. Many isokinetic machines are
resistance that can be produced by an individual (Figure also capable of isotonic assessment, isotonic referring to
15.64). In controlling the angular velocity and measuring constant load, or torque, throughout the range of motion.
the resistance, the muscle power produced becomes very Isotonic testing is a simulating of free weights, although
easy to find. Isokinetics also allow concentric, eccentric isokinetic machines also have the ability to allow for the

367
 Tidy’s physiotherapy

weight of the segment through the range of motion being
tested therefore giving a true representation of the torque
and power provided by the muscles.
CONCLUSION
This chapter highlights some of the background theory
and methods necessary for the analysis and interpretation
of the assessment of movement, forces, moments, strength
and power. This chapter should help the reader to under-
stand the movement patterns of individuals who are
pain- and pathology-free, and to become familiar with
some of the techniques used in the clinical research
literature. All these techniques may be applied to the
assessment of pathologies and conditions which affect
movement which can enable objective assessment and
monitoring of recovery through treatment and rehabil­
itation programmes.

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 Chapter
Sports management
Hilary Pape
INTRODUCTION
This chapter is aimed at the physiotherapist wishing to
work in the field of sports. It sets out to highlight the key
skills and knowledge base needed. Traditionally, physio-
therapists wanting to work in sports medicine would
consolidate the theory and practical skills learned in uni-
versity, under the supervision of senior clinical staff, before
embarking on a sporting career. For many recent graduates
this has become impossible owing to the paucity of tradi-
tional National Health Service (NHS) jobs. This chapter
aims to give inexperienced physiotherapists the necessary
background knowledge to work confidently and safely at
pitch, court or track side, and the rehabilitation setting.
For the purposes of brevity the term ‘pitch-side’ will be
used throughout to refer to any incident occurring acutely
in the competition or training setting.
Sports medicine is a broad, complex branch of health-
care encompassing several disciplines (Anderson 2003).
The physiotherapist working in sports needs a detailed
knowledge of the anatomy and physiology of neuromus-
culoskeletal systems, an understanding of other systems,
such as the cardiovascular and respiratory systems, and the
body’s response to exercise. It is vital to understand the
principles of first aid and acute injury management. A
working knowledge of the relevant sport, including the
psychological and physiological demands of that sport,
the mechanism of commonly sustained injuries and the
rules and regulations, is important. The legal considera-
tions, standards, and duty of care and negligence cannot
be ignored.
It should be noted that there are many excellent texts
centred around sports medicine and first aid. When sourc-
ing literature take care to ensure the guidance and advice,
particularly around legalities, is pertinent to the country
of application.
The author’s experience has been developed principally
in the sport of rugby league, therefore many of the exam-
ples given are taken from this sport.
16 
QUALIFICATIONS, SKILLS  
AND RELEVANT CONTINUING
PROFESSIONAL DEVELOPMENT
It could be argued that the physiotherapist working pitch-
side is principally a first aider. First aid is a skill in itself.
It has been defined as the assistance given to a casualty
immediately following injury or illness to maintain life
and/or prevent the problem getting worse until the casu-
alty can receive medical attention.
The Health and Safety (First-Aid) Regulations (1981)
require employers to provide adequate and appropriate
equipment, facilities and personnel to enable first aid to
be given to employees if they are injured or become ill at
work (HSE 2009). The Chartered Society of Physiotherapy
(CSP) service standard 16.2 (CSP 2005) states that all
physiotherapy staff involved in providing physiotherapy
services should receive training in the following:
• fire procedures;
• resuscitation;
• moving and handling;
• dealing with violence and aggression;
• infection control.
However, the legislation around first aid on pitch-side
is unclear. The Resuscitation and Emergency Management
Onfield (REMO) course (see Table 16.1), based in England,
was established in 2001 when the British Olympic Asso-
ciation (BOA) and the United Kingdom Association of
Doctors in Sport commissioned the development of an
immediate medical care and resuscitation course tailored
specifically for doctors and physiotherapists working in
sport. The REMO course is now a compulsory qualifi­
cation for UK doctors working in sports and exercise
medicine (Johnson 2010). Advanced Resuscitation and
Emergency Aid (AREA) was commissioned by the Football
Association (FA) in 2008 and has now become a man­
datory qualification for all medical staff working pitch-
side in the Premier League (Johnson 2010). The FA
369
 Tidy’s physiotherapy
Table 16.1  Where to get help
The Association of Chartered Physiotherapists In Sports
Medicine (ACPSM)
Sports Massage Association
Chartered physiotherapists interested in massage and soft
tissue therapies
British Association of Sports Exercise Medicine (BASEM)
Sport England
English Institute of Sport
UK Sport
The Physician and Sports Medicine
CogState Sport
100% Me
World Anti-Doping Agency WADA
‘Green Book’ on vaccines by Department of Health
Therapeutic Use Exemptions
Health and Safety Executive approved first aid courses
The National Sports First Aid Course
Resuscitation Council
Resuscitation and Emergency Management Onfield
also suggests a hierarchy of medical care where there must
be a doctor and Health and Care Professions Council
(HCPC)-registered physiotherapist present, including at
grassroots levels where, as an acceptable minimum stand-
ard, there should be a person in attendance at every match
and training session who is available to deliver emergency
and first aid (FA 2010). It is advisable then, that any health
professional working in this area does not solely rely on
their physiotherapy training, but also obtains a first aid
qualification. Many sports’ governing bodies recommend
their own specific first aid courses. The FA provide the FA
Emergency Aid Training Certificate and FA/1st4Sport First
Aid for Sport Certificate (FA 2010). If working at a profes-
sional level in rugby league you are required to hold the
Immediate Management on Field of Play (IMMOF) quali-
fication. The Rugby Football League is currently working
with the FA on a new first aid policy and training pro-
gramme for use in amateur rugby league and football.
By legal definition, correct first aid is that which is
approved by the voluntary aid societies for publication in
their manuals where this is used in training of a first aider
(Dunbar 2006). Therefore, it is recommended that at
370
http://www.acpsm.org
http://www.thesma.org/
http://www.csp.org.uk/professional-networks/cpmastt
http://www.basem.co.uk/article.php?id=331&catid=43
http://www.sportengland.org/
http://www.eis2win.co.uk/pages/default.aspx
http://www.uksport.gov.uk/
http://www.physsportsmed.com/
http://www.cogstate.com/go/sport/sport-world
http://www.ukad.org.uk/pages/100me
http://www.wada-ama.org/
http://www.dh.gov.uk/en/Publicationsandstatistics/
Publications/PublicationsPolicyAndGuidance/DH_079917
http://www.uksport.gov.uk/pages/therapeutic_use_
exemptions/
http://www.wada-ama.org/en/Science-Medicine/TUE/
http://www.hse.gov.uk/firstaid/training.htm
http://www.sportsmedicinecentre.org/scottish_
football.cfm?curpageid=746
http://www.resus.org.uk/siteindx.htm
http://www.remosports.com/
amateur level at least, a basic first aid course should be
undertaken. The National Sports First Aid course (see
Table 16.1), developed and delivered by the Faculty of
Sports and Exercise Medicine, is recommended by the
Association of Chartered Physiotherapists in Sports
Medicine.
Knowledge and skills needed
Physiotherapists aiming to work in sport should consider
the following:
• a working knowledge of the chosen sport;
• continuing professional development (CPD) in the
field of emergency medicine and sports medicine/
physiotherapy relevant to the role at the club;
• legal responsibilities;
• appropriate medical insurance, (check with the CSP
for individual cover);
• a working knowledge of World Anti-Doping Agency
(WADA) regulations (see Table 16.1);
• a working knowledge of concussion management.

Knowledge of sports
A working knowledge of the sport you are working in is
not essential but gives you invaluable insight which will
prevent mistakes being made that may impact on the
players, as well as on your ability to do your job. Think
about common mechanisms of injury (MOI) and gain an
understanding of the forces involved in your sport. This
can be invaluable if you do see the injury as it happens. It
helps to understand the physical needs and demands on
the athletes – this can affect how busy you are likely to be
on match day and what kit you always carry with you. In
contact sports, such as rugby or American football, frac-
tures, dislocations and lacerations are more common than
in swimming, for example. Aim to have a good under-
standing of the rules and bylaws of the sport – in sports
such as Judo you are not allowed to enter the mat or touch
a player in competition until the umpire has given you
permission or the player is disqualified. In many sports,
such as rugby league, you are given unconditional access
to the field of play in order to attend injuries. Knowledge
of the substitution rules can assist you to work with the
players and coaches to best serve everybody’s interests.
CPD
As with any area of clinical practice, practitioners must
maintain their CPD. In the sporting setting this may
include first aid training, which may extend to advanced
trauma management and advanced life support, to
advanced management of musculoskeletal injuries and
acute injury, to medico-legal training, etc. Professional
sporting requirements generally require a minimum of five
years post-qualification and Masters level postgraduate
training. At the time of writing this chapter, the prepara-
tions for the 2012 Olympic Games are in full swing.
Physiotherapists wanting to participate in events such as
the Olympic Games, the Commonwealth and World
University Games, or to work with elite athletes need to
be HCPC-registered physiotherapists and preferably mem­
bers of the CSP, hold a degree or graduate diploma in
physiotherapy, have a minimum of five years post-
registration experience and usually at least two years expe-
rience in training and competitive environments. Previous
experience of working at major games and multi-sport
experience, and active involvement with British Universi-
ties and Colleges Sports Association (BUCS) for student
sport, is not usually essential but considered an advantage.
Applicants are usually asked to provide proof of their
own CPD in the sports medicine fields, including evidence
of regular cardiopulmonary resuscitation (CPR) training.
A massage therapy qualification from a recognised Sports
Massage Association (SMA) course and a diploma or
MSc in Sports Physiotherapy is often considered an advan-
tage. It is recommended that physiotherapists join appro-
priate special interest groups. For those working in sport
the Association of Chartered Physiotherapists in Sports
Sports management Chapter 16
Medicine (ACPSM) provides an excellent support service,
a well-structured CPD programme, mentoring, a quarterly
journal, conferences and advanced notice of employment
and voluntary positions in sport. Evidence of working
towards, or having achieved, ACPSM silver level CPD
standards are usually regarded favourably when applying
to work at this level. It is worth mentioning at this point
that many of these positions are voluntary or only provide
an honorarium, with applicants expected to fund them-
selves and find their own accommodation. Applicants are
usually required to commit to a minimum period of two
weeks service when working for the host city at a major
games such as the Olympic Games in London in 2012.
However, working as part of Team England or Team GB,
or for BUCS at a World University Games, all accommoda-
tion, travel and food would be paid for.
Physiotherapists wanting to work in sport should con-
sider CPD in the following fields:
• Pre-participation Physical Evaluation (PPE);
• advanced first aid and trauma management
including:
 concussion management (see later discussion);
 on-field recognition of injuries;
 fracture and dislocation management;
 wound management;
 assessment of return to play protocols;
 thermoregulation;
 hydration/nutrition.
Legal responsibilities
When contracted by a team or athlete as the physiothera-
pist or first aider you have assumed a duty of care (Dunbar
2006). As long as you work within your scope of practice
and practise first aid skills in accordance with accepted first
aid practice, it is unlikely that a civil action for alleged
negligence would succeed (Dunbar 2006). It is worth
noting that if you are ‘employed’ as opposed to working
as a volunteer, the club may be liable in any litigation
proceedings.
It is important that physiotherapists working with chil-
dren (those under the age of 18) obtain an enhanced
Criminal Records Bureau (CRB) check (free for those in
voluntary positions) from the club at which you will work.
If you are being remunerated for your work you may have
to pay for your own CRB check. The majority of sport
national governing bodies (NGB) in the UK have embraced
child protection and safeguarding policies and further
embedded them at club level through accreditation
schemes such as Clubmark (Sport England 2011). It is
advised that you check with your club in the first instance,
but if you do require further support and information
contact the NGB directly. According to Dunbar (2006),
provision for sport is subject to Health and Safety
Executive (HSE) regulation and, as such, physiotherapists
working in sport should comply with the relevant safety
371
 Tidy’s physiotherapy
and reporting procedures. Serious accidents occurring to
athletes and/or first aiders are regarded as ‘notifiable’.
Medical insurance
Membership of the CSP will normally provide sufficient
professional and public liability insurance cover to work
in amateur sport. However, if diversifying into working
with elite athletes the limit of liability may not provide
enough cover. If working with racing animals, such as
horses and greyhounds, then it is advisable to contact the
CSP for further advice as the scope of activities insured
excludes animal or veterinary physiotherapy (CSP 2010).
Doping, and WADA and TUEs
The WADA promotes, coordinates and monitors doping
in sport. The WADA’s responsibilities in science and medi-
cine include, among others, scientific research, the prohib-
ited list, the accreditation of anti-doping laboratories and
therapeutic use exemptions (TUEs). Athletes may have ill-
nesses or conditions that require them to take medica-
tions. If the medication an athlete is required to take
happens to be on the prohibited list, a TUE may give
that athlete the authorisation to take the needed medicine.
The purpose of the International Standard for Therapeutic
Use Exemptions (ISTUE) is to ensure that the process of
granting TUEs is harmonised across sports and countries
(WADA 2010).
The rules and regulations surrounding drug use pre-
scribed or otherwise are complicated and may seem dra-
conian. The team doctor would normally deal with TUEs
at the elite level. Physiotherapists working in high level
sports should be extremely careful ‘prescribing’ any ‘medi-
cation’ (Taylor 2008). If in doubt, athletes are advised not
to use anything no matter how innocuous it may seem.
More information can be found on the UK Sports, WADA
and the ‘100% ME’ websites (see Table 16.1).
Concussion management
Concussion or traumatic brain injury (TBI) is common in
sports. About 90% are mild in nature and are referred to
as mild TBIs (mTBI) but obviously all TBIs have the poten-
tial to develop serious complications (Solomon et al.
2006). The following discussion provides an overview
only and should be supported by further reading and
attendance on trauma management courses.
There appears to be no clear definition of concussion.
However, the Concussion in Sport (CIS) Group at the
International Conference on Concussion in Sport in
Prague (2004) offered the complex definition below
(McRory et al. 2005). This CIS definition represents a con-
sensus of opinion from experts in the sports medicine field
and is recommended as the most current (Solomon et al.
2006):
Sports concussion is defined as a complex
pathophysiological process affecting the brain,
372
induced by traumatic biomechanical forces.
Several common features that incorporate
clinical, pathologic and biomechanical injury
constructs that may be utilised in defining the
nature of a concussive head injury include:
1. Concussion may be caused either by a direct
blow to the head, face, neck or elsewhere on
the body with an ‘impulsive’  force transmitted
to the head.
2. Concussion typically results in the rapid onset
of short lived impairment of neurologic
function that resolves spontaneously.
3. Concussion may result in neuropathological
changes but the acute clinical symptoms
largely reflect a functional disturbance rather
than structural injury.
4. Concussion results in a graded set of clinical
syndromes that may or may not involve loss
of consciousness. Resolution of the clinical
and cognitive symptoms typically follows a
sequential course.
5. Concussion is typically associated with grossly
normal structural neuro imaging studies.
The review also advised that in many cases post-­
concussive symptoms may be prolonged or persistent
(McRory et al. 2005).
Clinical note
The signs and symptoms of concussion are varied and
include:
• confusion;
• amnesia;
• headache;
• dizziness;
• ringing in the ears;
• nausea or vomiting;
• slurred speech;
• perseveration;
• fatigue;
• memory or concentration problems;
• sensitivity to light and noise;
• sleep disturbances;
• irritability;
• depression.
In children and other patients who find it difficult to
communicate take note of listlessness, tiring easily, a
change in eating or sleeping patterns, lack of interest in

toys and loss of balance or unsteady walking. Not all of
the above symptoms may be present, and may develop at
different stages. Loss of consciousness (LOC) has tradi-
tionally been viewed as the most significant symptom in
the diagnosis and determination of severity of concussion.
LOC requires immediate medical attention to ensure a
patent airway and avoid cardio-respiratory failure until
such is ruled out or the casualty regains consciousness.
However, it is now thought that retrograde (before) or
antegrade (after) amnesia is of more significance. Should
LOC occur post-traumatic incident (as opposed to sudden
collapse or syncope) it is advisable to assume spinal injury
until such time as this can be ruled out. The casualty
should be managed appropriately (log rolling, etc.) unless
the airway is compromised. Again, the reader is advised to
complete first aid and trauma management training to
develop the necessary skills to manage the unconscious
casualty.
Assessment of concussion involves recognising the
above symptoms, which may be difficult if the symptoms
are mild. There are several pitch-side assessment strategies
and neuropsychological tools that can be used to assess
concussion. Many of these tests, to some degree, rely on a
pre-season baseline test having being performed, for
example Post-Concussion Scale – Revised (PCS-R) or
Head Injury Scale (HIS) (Solomon et al. 2006). The tests
are then rerun post-suspected concussion and the scores
compared. Maddock’s Questions are commonly used to
assess players in the field of play. Developed in 1995 by
Dr D.L. Maddocks and colleagues these are a set of stand-
ardised questions that can be adapted to particular sports
and are a qualitative measure of the neuropsychological
state of a player having sustained a head injury. Questions
include:
• Which field are we at?
• Which team are we playing today?
• Who is your opponent at present?
• Which half/period is it?
• How far into the half is it?
• Which side scored the last touchdown/goal/point?
• Which team did we play last week?
• Did we win last week?
The athlete’s ability to answer the questions, even if the
answer is correct, should alert the first aider to the possibil-
ity of concussion.
CogState Sport is a well-recognised computerised con-
cussion test and management system for use by profes-
sional, elite and amateur athletes all over the world.
CogState Sport is proven sensitive to mild cognitive
changes and helps guide medical decisions about return to
activity and rehabilitation. Athletes take a baseline test
before the season begins (or when uninjured). Testing
computers do not need to be connected to the internet for
testing. Once the tests are finished, they are submitted, via
the internet, to CogState, using a password-protected data
Sports management Chapter 16
transfer system. A report will then be sent back by email
as to whether the baseline test was satisfactory or whether
the athlete needs to take another test. Disadvantages
include time and the need for equipment to carry out the
baseline tests. There are recognised paper-based and side-
line tests available which can be performed as a baseline
test preseason then used pitch-side to monitor a player’s
progress. The CogState Sport website is worth a visit (see
Table 16.1) and provides invaluable advice, information
and guidance on concussion and its management for
anyone working pitch-side. While preseason testing occurs
routinely in professional and elite sports, it is unlikely to
occur at amateur level. The principal reasons for this may
be lack of facilities and staff. It is likely that the physiother-
apist working at amateur level will be the sole medical
practitioner. It is difficult to monitor players carrying out
the neuropsychological tests while trying to keep an eye on
the game in process. In addition, in professional and elite
sports you have a captive audience in that these measures
are a necessary and recognised part of competing at high
level sports and often form part of contractual agreements
of playing for a club. In the amateur setting, athletes may
not recognise the importance of baseline testing and there-
fore refuse to participate. It is worth pursuing, however, as
we attempt to raise standards of care in sports medicine.
As with the definition of concussion, there is little con-
sensus on when concussed players can return to play.
Medical treatment for concussion comprises principally
of rest (McRory 2001a). The aim of concussion manage-
ment, therefore, is to prevent the athlete returning to
sport before their brain has recovered. Many sports gov-
erning bodies will provide their own guidelines on return
to play – particularly at professional level. Usually, this
decision will be the responsibility of the club doctor. At
amateur level where the onus may fall on the physiother-
apist the main consensus seems to be that no player
should be allowed to return to the field of play until all
the symptoms of concussion have resolved. This may
take several days (McRory et al. 2005; Solomon et al.
2006). It should be remembered that there is some evi-
dence that TBI is cumulative and much of the research
shows that a player’s risk of sustaining a concussion
increases once they have already had one (Solomon et al.
2006). Players sustaining repeated head injuries through-
out a season may suffer moderate cognitive changes and
there is some evidence to suggest there is a relationship
between repeated concussion and Alzheimer’s disease
and depression. Where there is consensus within concus-
sion management it is that any child sustaining a sus-
pected concussion must be referred to hospital.
Second impact syndrome
Second impact syndrome (SIS) has been defined as a syn-
drome occurring when an athlete sustains a second head
injury before the symptoms of the initial injury have
373
 Tidy’s physiotherapy
resolved. It is thought to be a disruption in the autoregula-
tion of the brain leading to oedema and an increase in
intracranial pressure causing herniation of the brain and,
ultimately, death (Solomon et al. 2006). Although SIS
is well documented in the literature, Dr Paul McRory, a
renowned neurologist specialising in sport and concus-
sion, has questioned the existence of SIS. McRory (2001b)
suggests the evidence for such SIS is not compelling and
that SIS is more likely to be a clinical condition represent-
ing diffuse cerebral swelling. He suggests that clinicians
abandon the term ‘second impact syndrome’ and refer to
the syndrome as ‘diffuse cerebral swelling’. Despite the lack
of a clear consensus, most authors agree that no player
should be allowed to return to play until all symptoms
have resolved (Solomon et al. 2006).
Summary
Anyone working pitch-side should aim to increase their
awareness of the recognition, assessment and manage-
ment of concussion. Most basic first aid courses will
address concussion but more advanced trauma manage-
ment courses will give a more comprehensive knowledge
base. Readers are directed to Solomon et al. (2006) and
the CogState Sport website for further information on the
recognition, assessment and management of concussion.
ROLE OF THE PHYSIOTHERAPIST  
IN SPORT
It is worth considering what the role of the physiotherapist
is in preparation for competition/games and pitch-side. If
you are in a position to be offering rehabilitation for
players in between competition you will be likely working
in a similar situation to that of musculoskeletal outpa-
tients taking a detailed subjective and objective history,
designing an appropriate management plan with the aim
of facilitating players return to play. At pitch-side and on
competition day the role is more complex. Physiothera-
pists working for professional clubs are likely to be part of
a multi-disciplinary team of what is commonly known as
‘backroom staff’. This team will include the coach plus
assistants. There may be a dedicated kit man and statistics
recorder and team doctor. This means you will have a team
to rely on and help you out with carrying equipment and,
possibly, match preparation. In the amateur setting this
is less likely and experience has demonstrated a need
to think outside your normal scope of practice. You may
find you take on an almost parental role and become
responsible for remembering sub suits for players sitting
on the bench at pitch-side when the weather turns cold,
sun cream when its hot and stud keys, etc.
In the professional game you are likely to have a clearly
defined role limited to pre-match preparation, for example
strapping and pitch-side first aid. In the amateur setting
374
you may find yourself being asked to deal with spectators
and their families, and even the match officials. You will
need to make the decision about how to handle such
requests but it is worth remembering that your first
responsibility is to the players. If you are being asked to
deal with an incident off pitch, inform the referees/
umpires and get play stopped.
Key preseason considerations
As well as the skills and knowledge discussed earlier there
are some key preseason considerations to be aware of.
Before embarking on pitch-side it is advisable to consider
your own health and protection. Ensure you have received
the appropriate vaccinations and immunisations as for
any healthcare worker, for example tetanus and hepatitis
B. Pitch-side first aiders should aim to adopt the same
standard precautions that all healthcare workers do.
Table 16.1 contains a website address for the Green Book
on vaccines produced by the Department of Health which
gives the most up-to-date advice. However, you can visit
your general practitioner (GP) for further advice. All
therapists working pitch-side or otherwise are referred to
the epic2 guidelines for preventing healthcare-associated
infections (Pratt et al. 2007); these are available from
the Department of Health website at: www.doh.gov.uk/
HAI and the Hospital Infection Society website at:
www.his.org.uk. These contain standard principles for pre-
venting infections and should be adopted by all healthcare
workers coming into contact with patients’ blood or
bodily fluids. They are a set of principles designed to mini-
mise exposure to and transmission of a wide variety of
microorganisms. On pitch-side ensure you wear suitable
personal protective equipment, for example gloves or face
protection depending on the sport you are working with
and the risks involved (e.g. bodily fluids – blood, sweat,
saliva). In cold weather you are likely to be well covered
but be aware in warm weather or indoor sports that you
may have exposed skin and are therefore at risk of splashes
and inoculation injuries. You may choose to wear goggles
and protective clothing of some kind depending on the
sport you are working with and the risks involved.
If dealing with children check that your enhanced CRB
and first aid certificates are current.
You may need or desire to carry out preseason baseline
preparation checks on athletes. As discussed in the section
on concussion, this may not be appropriate or be difficult
to implement. However, it is good practice if it can be
done. Aim to get to know all the members of your squad
and gain a basic medical history so that you know who is
asthmatic or who has allergies or other pre-existing condi-
tions. Ensure you know who to contact in case of emergen-
cies, etc. You may need to perform an inventory of what
equipment is available to you and decide if you need to
order more supplies. What equipment you may need is
discussed later in the chapter.

Consider your own match-day clothing. Do you need
studded boots or waterproofs, including trousers? You
may get some team kit supplied, although it may not fit.
You may be expected to travel and work in a different kit
from what you wear post-match, especially when working
at a professional level.
Sort out your lines of communication – this is often a
problem, particularly in the amateur setting. Club staff
often forget that the physiotherapist needs to know what
time everybody is meeting and what time the team bus is
leaving, etc. Obtain as many telephone numbers and
email addresses as possible, including coaching staff,
players and other backroom staff.
Finally, you will hopefully be getting paid for your serv-
ices. Be warned that pay, particularly at amateur level, is
not usually high. You will generally find at a professional
level you will be salaried but you are often expected to
work long, unsociable hours. Most competitive sports
occur at weekends and evenings: you will be expected to
be there. In amateur sports, clubs will generally ask you
what you want to be paid but are rarely able to pay the
same hourly rate afforded to NHS staff. When negotiating
your pay ensure the club recognises that when playing
away fixtures, you should be paid from the minute the
team bus sets off to when it arrives back and not just for
the period you are pitch-side. It is usual, however, for clubs
to agree a set fee for games and a set fee for rehabilitation
nights. Some sports have more expendable income than
others. You will need to use your discretion and be realis-
tic, but try not to sell yourself or your profession short.
Key pre-match considerations
These are particularly important for away games/
competitions. You need to ensure you take everything
with you and that you are prepared for almost every
eventuality. Much of this comes with experience, but
experience dictates if you do not have it with you
you’ll need it!
Make sure you have discussed with the coaching staff
how long you are likely to need for pre-match preparation.
Most teams/athletes will require a warm-up. All these
factors need consideration, along with travel time, to
ensure the departure time is early enough.
If travelling away, ensure the medical kit is on the team
bus. This means if the bus is caught up in traffic congestion
you can begin to strap on the bus. Obviously, if using
scissors wait until the bus is stationary!
Pitch-side
Pitch-side equipment
The following is a possible list of contents for a pitch-side
medical bag. It does not represent an exhaustive list and
is taken from a collection of sources and personal experi-
ence. The contents of your medical kit may be dictated by
Sports management Chapter 16
the sport(s) you are involved in and may continue to be
revised and updated in response to incidents that occur.
• Crepe bandages/Tubigrip.
• Semi-compressed chiropody felt – useful for all sorts
of things, including as an adjunct to compression
bandaging.
• Elastic adhesive bandage (EAB) (various sizes).
• Zinc oxide tape (inelastic) (various sizes).
• Disposable nitrile gloves – if working in hot weather
carry a size larger than normal as they will be easier
to put on and take off.
• Gauze swabs for mopping up blood, cleaning
wounds. Consider disposal carefully.
• Plasters (non-allergenic/waterproof).
• Sterile, non-adherent wound dressings (various sizes).
• Nasal plugs.
• Triangular bandages.
• Sterile eye packs/physiological saline for irrigation.
• Milk sachets/pots for storing lost teeth.
• Petroleum jelly.
• Massage mediums.
• Nasal decongestants-beware TUE regulations.
• Scissors (safety type).
• Nail clippers.
• Blanket – wool/space (foil).
• Small towel.
• Safety pins.
• Splints.
• Neck collar – various sizes – these need to be applied
correctly. Ensure you have appropriate training.
• A pocket mask or resuscitation mask/bag-mask-valve/
airway (only to be used by trained individuals).
• Water bottle.
• Ice/cryotherapy equipment.
• Mobile phone.
• Stretcher/spinal board – spinal boards are only safe
to use if you have a competent team who are well
practised in spinal boarding. You may be as well
using manual immobilisation and wait for
paramedics in suspected spinal injury.
• Insulation tape.
• TBCo (Friar’s balsam) – this is excellent stuff and is
used as pre-strapping/steristrips to ensure adherence of
tape. Avoid contact with eyes and mucous membranes.
• Cotton buds.
• Paracetamol.
• Toilet roll.
• List of players/contact details.
• Advice sheets for head injuries, etc.
PRINCIPLES OF FIRST AID
The following discussion is an overview only. It is not
intended to replace attendance on a first aid or trauma
375
 Tidy’s physiotherapy
management course but highlights the main principles of
pitch-side first aid.
Key points
The key concept is to maintain life and/or prevent the
injury getting worse. Your skills as a physiotherapist, for
example your anatomical and physiological knowledge,
are invaluable, particularly in the rehabilitation setting
but essentially at pitch-side you will be required to apply
the principles of first aid:
• assess the situation quickly and safely and summon
appropriate help;
• protect the casualty and others from danger;
• identify (where possible) the nature of the problem;
• prioritise the casualties;
• give early and appropriate treatment.
Pitch-side assessment is different from a normal muscu-
loskeletal assessment in that the aim is less about obtain-
ing a diagnosis and more about determining whether a
player needs to be removed from the field of play. Obvi-
ously, if a player had sustained a TBI they may have lost
consciousness and their airway may be compromised
necessitating on-field emergency management. A limb
injury may initially seem serious to you and the player if
you rely solely on pain as a guide. When you arrive at the
scene do not be in a hurry to act. Unless you suspect airway
compromise stop and ask the player what has happened.
Do not assume anything: ask them where it hurts. You
would be surprised how many players will be clutching a
non-injured limb. If you did not see the mechanisms of
injury, try and ascertain it to give you an idea of the forces
involved. These questions also have the advantage of
allowing the player time to calm down and acute pain
time to settle. Many ligament tests will be difficult at the
scene owing to pain and muscle spasm. If the rules allow
it, remove the player from the field and assess at pitch-side
so you are not under pressure from referees or umpires. It
is often more appropriate to apply the PRICEM (pro­
tection, rest, ice, compression, elevation, mobilisation/
movement) principles (see below), then assess after a
period of time to allow the initial symptoms to settle. It is
not unknown for players to be removed from the field and
then to find their injury was not as serious as first thought.
Put some thought into how to remove a player from the
field. If they can, let them get up and hop/limp off under
their own steam or with help. Protect you own back, use
other players or bystanders if you are a small physiothera-
pist dealing with a large player. If you suspect serious
fractures, such as femoral or spinal, you may need to
have the player stretchered off. In the professional setting
there should be a trained team (possibly including the
376
physiotherapist) to do this. At amateur level you may be
on your own. It is not advisable to spinal board a player
without a practised team and appropriate training. In
these cases immobilise manually and call an ambulance,
no matter how long this takes. If you suspect a limb frac-
ture you may choose to immobilise and send the player
to accident and emergency. It is a good idea to familiarise
yourself with the OTTAWA rules. These are a set of well
documented guidelines to decide if a patient with foot,
ankle or knee pain should be offered X-rays to diagnose a
possible fracture. Many unnecessary X-rays are taken,
which can be costly, time-consuming and pose a possible
health risk. If you suspect soft tissue injury you may only
be able to ice, elevate and immobilise until after the
match, especially if you are working solo.
Practicalities of injury management
PRICEM and the principles of soft tissue injury manage-
ment in relation to inflammation and healing are covered
in Chapter 12. However, it is worth discussing some of the
practical applications of these principles at this point.
For more details on PRICEM readers are directed to
Chapter 12 and the PRICEM guidelines produced by the
ACPSM (see Table 16.1) for further reading.
Protection
It is a good idea to keep a selection of braces and crutches
to offer local protection and rest. This avoids the need for
adhesive strapping which players may remove, hence
losing the benefit. Although not usually a problem in
professional sports, at amateur level where finances are
tight, you may have to be inventive. It is usual to dispose
of knee braces, etc. given to NHS patients. You could con-
sider keeping them and washing and re-using them on
other players (unless they are soiled enough to pose a
significant infection risk). Many athletes require strapping
every match. Use of semi-rigid braces which can be
used again can save a lot of money. Wash them in as hot
a wash as possible after each match as sweat and dirt
will degrade them.
Rest
Experience shows that many injured players will keep
‘testing’ the injury constantly, breaking fragile fibrin bonds
as they try and repair the injury. Using crutches/braces as
above, encourages the athletes to stop and rest.
Ice
The evidence base suggests that wet ice (e.g. a wet towel
ice bag) applied to soft tissue injuries is most effective
(Bleakley and MacAuley 2007). Immersion is useful
for non-uniform areas such as hands. However, while

efficacious, these methods may be impractical in certain
settings. If injured athletes are about to embark on a long
coach trip home from an away game it might be prudent
to use sealed methods of cryotherapy, such as Cryocuff™
to avoid spills and wet seats. Although these systems do
not appear to cool the tissues as effectively, they do add
some compression. Recent evidence suggests that com-
pression and ice may be more effective in limiting oedema
than ice alone (Bleakley and MacAuley 2007) and that ice
is more important in reducing the effects of secondary cell
death owing to tissue hypoxia (Merrick 2002).
Compression
The evidence for the efficacy of crepe bandages versus
Tubigrip in the prevention of oedema is not yet conclu-
sive. Until there is a consensus the author recommends
Tubigrip. It is easier to apply safely and patients can take
it off and re apply as necessary. Tubigrip can also be used
for protection. Several sizes will be required.
Elevation
Achieving elevation at pitch-side and when travelling
home can prove a logistical challenge. Consider using kit
bags, spare clothing, support staff and even supporters to
support lower limbs. The author has a large medical kit
bag containing a small folding stool. Upper limbs can be
held by the uninjured arm or fold the player’s shirt up over
the injured arm to achieve moderate elevation rather than
applying complicated triangular bandage slings. If higher
level elevation is required (for example to stop palmer
bleeding) lie the player down where possible and use a
bystander to maintain the injured limb’s position while
applying compression.
Mobilisation/movement
Be aware of the inflammatory processes, tissue repair and
healing (review Chapter 12). Give appropriate advice to
the players about suitable levels of activity before you see
them in the rehabilitation setting. If this is not possible
give appropriate advice about PRICEM self-management.
Suggest the player visits their GP for referral to physiother-
apy and to obtain a sick note if necessary. Keep a list of
local private physiotherapists that you can refer your
players to. Many private practitioners will offer reduced
rates to clubs if they are guaranteed a ‘regular supply’ of
patients.
Summary
Pitch-side physiotherapy is principally a first aid role.
Ensure you attend a recognised first aid course to supple-
ment your physiotherapy training. Consider attending an
advanced trauma management course. This will give you
more confidence in dealing with serious situations and
injuries.
Sports management Chapter 16
ROLE OF THE TEAM DOCTOR
At this point it is appropriate to consider the role of the
doctor in sports. This will largely depend on the setting in
which you are working. In the amateur setting the doctor
is likely to be a volunteer – possibly a spectator, supporter
or player willing to help out. However, in the professional
setting it can become a little more regimented but may
include:
• medical care of players;
• pitch-side management of injuries in conjunction
with the physiotherapist. The doctor will usually take
a back seat until needed;
• secondary referral of injured players to specialist
services;
• ensuring the medical needs of the players are met
through monitoring and evaluation, including
prophylactic medical screening/pre-participation
screening;
• TUEs – see earlier discussion;
• post-concussion return to play tests;
• identification, sourcing and distribution of medical
equipment;
• oxygen and emergency drug box care;
• the care of the away team;
• keeping up-to-date medical records;
• liaising with other medical staff relevant to the
players’ welfare for international or representative
duty;
• providing in-service/CPD training for the medical
team;
• working within the guidelines of medical care and
confidentiality as currently set out by the BOA;
• working closely with coaching and management
staff.
It should be noted that the team doctor will not be
responsible for crowd cover. Separate medical cover for the
crowd should be provided by the venue.
Summary
The author summarises the role of the physiotherapist in
team sports as six ‘knows’:
1. Know your sport. Aim to research common injury
patterns and mechanisms of injury. Understand how
player positions may lead to predisposition to
certain injury patterns. Familiarise yourself with the
rules and bylaws of your sport.
2. Know your players. Get to know your athletes – their
age, medical history and any predisposing factors to
injury. Learn whether they suffer from repeat
injuries, such as ankle sprains. You may be able to
influence this. Get to know their superstitions. While
this may not seem important, an awareness and
377
 Tidy’s physiotherapy

tolerance of their superstitions, such as not wanting
to be strapped until the last minute or will not wear
yellow insulation tape, can make for smooth running
of pre-match preparations.
3. Know your coaching staff. This is particularly
important. If you can gain the confidence of the
coaching staff they will support you in dealing with
difficult players and support you when you ask for
equipment. Learn their particular ways of working.
Have they had experience of working with a
HCPC-registered physiotherapist before? Experience
suggests many coaches are used to volunteer ‘sponge
men’. Coaching staff may not understand your
refusal to allow a player back on the pitch after a
TBI, even when they appear to have recovered. One
suggestion is to put together a manual or handbook
for the players and coaching staff explaining your
management of common injuries. The team can read
this in their own time and concentrate on your
rationale without the distractions and concerns of
match day. Discuss how long is needed for pre-
match warm-up. Explain you cannot effectively strap
a sweating player so you need enough time for
pre-match strapping before the warm-up.
4. Know the match officials. Again, this might not
seem important but if you remain professional
and helpful to match officials it can only benefit
your team and will ensure they support you in any
major incidents.
5. Know your equipment/facilities. It is important never to
assume anything when travelling to an away fixture.
Check travel and weather reports, particularly if you
are making your own way to a fixture. Check what
equipment you will be provided with in the away
changing rooms. You may not be provided with a
treatment couch and may always choose to take your
own portable couch. It is a good idea to take an ice
box pre-filled with ice in case the club you are
visiting does not have any, or enough. Many amateur
clubs provide few, if any, facilities for mixed gender
changing. Female physiotherapists may find they
have to get changed after the game in the ladies
toilets. Carry wet wipes so you can freshen up. On
arrival check where the nearest accident and
emergency facilities are, and access to the pitch for
an ambulance. Basically, be prepared for nothing
and everything!
6. Know your stuff. This refers to your CPD, first aid
training combined with your physiotherapy training.
The CSP and HCPC standards mean that working,
even in the amateur sports setting, means you need
to practise evidence-based medicine. Regular CPD in
any form will give you the confidence and the
knowledge to practise safely and competently in an
environment where you may be the sole medical
practitioner.
Working in sport is a rewarding experience. It
tends to be slightly more relaxed than traditional
NHS environments. It can give the physiotherapist
scope to work independently and devise individual
ways of working. It can give rise to many
opportunities, such as representing your city, county
or country, travel and making new friends and
colleagues. Ensure you maintain the professional
standards that you signed up for when you obtained
your licence to practise and you will find the
sporting environment one of the most rewarding
experiences of your professional career.

ACKNOWLEDGEMENTS

The author would like to acknowledge and thank Stephen Fairhurst, safeguarding consultant; Lynn Booth, MSc, MCSP,
Clinical Lead - Physical Therapies Service, London Organising Committee of the Olympic Games and Paralympic Games
and Andrea Denton RGN, MA, MSc, infection prevention and control nurse.

FURTHER READING

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Bahr, R., Mæhlum, S., 2004. Clinical
Guide To Sports Injuries. Human
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Boxill, J., 2003. Sports Ethics: An
Anthology. Blackwell Publishing,
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Cerny, F.J., Burton, H.W., 2001. Exercise
Physiology for Health Care
Professionals. Human Kinetics,
Leeds.
Eustace, S.J., Johnston, C., O’Byrne, J.,
et al., 2007. Sports Injuries:
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Fleck, S.J., Kraemer, W.J., 2004.
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Gardiner, S., James, M., O’Leary, J.,
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379
 Chapter
Pain
Lester Jones, G. Lorimer Moseley and Catherine Carus (Case study development)
INTRODUCTION
Pain is a common and normal human experience. Pain
helps us to learn to adopt protective behaviour when we
are threatened and safe behaviour when our body has
been injured. Pain usually seems like a reasonably predict-
able experience. In a normal state, receptors in the tissues
of the body respond at reasonably predictable thresholds
of stimulation. When they do respond, they initiate action
potentials that travel along peripheral neurones into the
spinal cord. Neurotransmitters released from these neu-
rones often activate secondary neurones, which send
action potentials up the spinal cord to the brain. The brain
then evaluates this information. Often, pain is perceived
in the tissues that were stimulated. This might seem
simple, but it is not.
Definition
The International Study for the Association of Pain
defines pain as ‘…an unpleasant, sensory and emotional
experience associated with actual or potential tissue
damage, or described in terms of such damage’ (Merskey
and Bogduk 1994).
There are several key parts of this definition.
• Firstly, although the nociceptive system is critical for
detecting dangerous stimuli and alerting the brain,
pain is not simply the transmission of noxious
sensory information (nociception). Rather, pain has
potentially profound cognitive and emotional
influences, just like other perceptual states (even
vision – think of your favourite visual illusion and
notice that what you see is not necessarily an
17 
accurate reflection of the light that is hitting the light
receptors on your retina).
• Secondly, pain is not a measure of tissue damage,
which means that tissue can be injured but not
painful, and painful but not injured.
• Thirdly, pain is about threat to body tissue, not
about a particular mode of sensory input. This sets
pain apart from other information that is sent from
our tissues to our brain: the so-called somatic senses.
It is this threat-specific quality that makes pain
critical for protection and preservation of the body:
pain seems to be the conscious component of a
complex defence system.
• Finally, there are many unconscious components
of this defence system, all of which can influence
each other and influence pain. Thus, pain is a
fundamentally conscious process, which is preceded
and accompanied by a range of responses, most of
which are not conscious. According to this model of
pain, when someone is in pain, we can be sure that
their brain is concluding that tissue is in danger and
that they should take some sort of action to get the
tissues out of danger (Wall 1999; Butler and Moseley
2003).
THE PHYSIOLOGY OF PAIN
This section will discuss the physiology of pain under
three categories:
• activation of the nociceptive system;
• sensitisation of the nociception/pain system;
• pain modulation via psychological and social
influences.
Within each category, we will separate peripheral from
spinal and brain mechanisms, when it is appropriate to
do so.
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 Tidy’s physiotherapy

Activation of the nociceptive system
Peripheral transmission
The peripheral nervous system is well studied but not
completely understood. Many types of neurones in the
periphery are thought to contribute to nociception (Meyer
et al. 2006). The most important of these neurones are
probably Aδ and C fibres – conventionally called nocicep-
tors – although many Aδ and C fibres also respond to
non-noxious inputs (Craig 2002).
For the sake of clarity, we will classify Aδ and C fibres
as primary nociceptors (see Table 17.1).
Nociceptors are found in most tissues of the body
and can be considered to have the principal role of detect-
ing dangerous thermal, mechanical or chemical stimuli.
Studies have attempted to identify activation thresholds
for different noxious stimuli (the activation threshold is
the lowest intensity of a stimulus that produces an action
potential in the nociceptor). While there is variability
between individuals, there seems to be a predictable range
of activation thresholds for primary nociceptors in healthy
pain-free individuals.
Thresholds of unsensitised nociceptors
• Mechanical – two classes:
 mechanically sensitive afferents: early response
(e.g. to pinch);
 mechanically insensitive afferents: > 600 kPa (see
Meyer et al. 2006);
• Thermal:
 heat: 41–49°C (Tillman et al. 1995);
 cold: 6.7°C (hand)–11.8°C (forearm); 0°C (Kelly
et al. 2005);
• Chemical (concentrations that have elicited pain):
 acetylcholine 1% solution (Schmelz et al. 2003);
 capsaicin 0.1% solution (Schmelz et al. 2003).
Spinal transmission
Primary nociceptors terminate in the dorsal horn of the
spinal cord. The dorsal horn consists of numerous layers,
which are defined according to the projections and struc-
tural and functional properties of their neurones. The
majority of nociceptors terminate in laminae I (Aδ fibres
usually terminate here), II (C fibres usually terminate
here) and V (Aδ, C and Aβ fibres all terminate here).
Lamina II neurones project to other laminae and can be
excitatory or inhibitory. Because peripheral input onto
lamina I fibres is almost exclusively nociceptive (Aδ), the
neurones that project from here are called nociceptive-
specific second order neurones. Because peripheral input
onto lamina V second-order neurones includes Aδ, C and
Aβ fibres, lamina V second-order neurones tend to respond
over a wide range of stimulus inputs, which is why they
are called wide-dynamic range neurones.

Transmission from the dorsal horn to the brain

Table 17.1  Comparison of characteristics of Aδ and
C fibres. Characteristics referred to by the letter ‘a’ There are five ascending pathways for nociceptive infor-
are physiological, while ‘b’ describes consequences mation. The largest is the spinothalamic tract, which in­­
for the nature of pain. cludes neurones that originate in laminae I and V. Other
pathways include the spinoreticular tract, spinomesen-
Characteristic Aδ C cephalic, cervicothalamic and spinohypothalamic. Impor-
tantly, there is not a single nociceptive pathway, nor is
1. Conduction Fast (4–36m/s) Slow there a single target location (a ‘pain centre’) in the brain.
speed* (0.4–2m/s) Rather, there are many sites within the central nervous
system (CNS) at which nociceptive input is processed and
2a. Accommodation Fast Slow
modulated.
(adaptation)

2b. Pain duration Brief Long Brain transmission

3a. Receptive field Small Large The brain is defined here as that part of the CNS that lies
3b. Localisation Precise Diffuse
above the spinal cord. There are several important charac-
teristics of how nociception is handled by the brain.
4. Sensory quality Sharp, pricking Aching, dull,
burning Parallel processing
5. CNS response Reflex, analysis Emotional, Many brain areas are involved in pain. Most often, the
suffering thalamus, insula, primary (S1) and secondary (S2) soma-
tosensory and prefrontal cortices are involved. These areas
*Because Aδ fibres conduct more quickly, the pain that is evoked are called the pain matrix (Apkarian et al. 2005) (Figure
usually commences sooner than it would if only C fibres were 17.1). However, these areas are never the only areas
activated. involved and they are not always all involved – the pattern
(Reproduced from van Griensven (2005); see also Craig (2002)
of brain activation varies greatly between, and within,
and Meyer et al. (2006).)
individuals.

382
 Pain Chapter 17

RT.LAT LT.LAT RT.MED LT.MED SUP

A

S1 ACC

B C

S2 IC

D E

Figure 17.1  Pain evoked activation in the human brain. (a) Surface-rendered image obtained using positron emission
tomograms (PET). It shows areas of the brain that are more active during painful thermal stimulation than during non-painful
thermal stimulation. (b–e) Images obtained using functional magnetic resonance image (fMRI) of a similar stimulus. This time,
cross sectional views are shown so that we can see activation of primary and secondary somatosensory cortices (S1 and S2),
anterior cingulated and insular cortices (ACC and IC). Because the areas shown in each image are more active during pain
than during non-painful heat, we take them to be important in producing pain. (Part (a) reproduced from Casey et al. (2001); (b–e)
adapted from Bushnell et al. (1999) with permission.)

Different aspects of pain seem to involve
different brain areas
In an attempt to clarify the potential roles of different
brain areas in pain, some authors conceptualise two
systems. The medial nociceptive system includes the
medial thalamic nuclei, anterior cingulate and dorsola-
teral prefrontal cortices. It is described as slow and only
broadly somatotopic, which means it does not have the
capacity to code in detail the location in the body at
which the stimulus occurred. Activity in this system has
been proposed to subserve the affective-emotional dimen-
sions of pain, i.e. the unpleasantness of pain rather
than the intensity and quality. This aspect of pain may
have value to the person experiencing pain by triggering
behaviour that demands other people’s attention (Goubert
et al. 2009).

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 Tidy’s physiotherapy

The lateral nociceptive system includes the lateral tha-
lamic nuclei and the primary (S1) and secondary (S2)
somatosensory cortices. It is described as fast and is highly
somatotopic, which means it is able to code, in great
detail, the tissue location at which the stimulus occurred.
Activity in this system is proposed to subserve the sensory-
discriminative aspects of pain, i.e. the intensity of the
pain and the sensory characteristics of the stimulus (e.g.
warm, sharp, deep, superficial). The intensity and unpleas-
antness of pain can be independently manipulated (e.g.
Moseley 2007a).
Multiple inputs: The neuromatrix theory
Melzack (1990) proposed the neuromatrix theory as a
way of conceptualising how myriad inputs and factors
affect pain and nociception (Figure 17.2). Inputs and
factors in that theory include previous learning and past
experiences, immune and endocrine states and re­sponses,
activity in the autonomic nervous system, and informa-
tion coming from nociceptors and other sensory recep-
tors. The theory suggests that pain will occur when all
these elements are evaluated and a specific network of
neurones in the brain is activated. Melzack calls each par-
ticular network of neurones a neurosignature (or ‘neuro-
tag’ (described by Butler and Moseley (2003)), which is
analogous to the representation concept used in cognitive
neuroscience literature (see Damasio (2000) for a review
of representation theory). Remember that this is a theory
and that the brain physiology underpinning pain and
consciousness is not well understood.

Tissue
Platelets damage
CRH
Macrophage IL1 Immune cells

H+
TNFβ
IL6 Adenosine
LIF
Plasma extravasation
ATP Glutamate
vasodilation
Mast cell ASIC
NGF
IL1β A2
iGluR Keratinocytes
P2X3
Bradykinin
TrkA mGluR1,5
PAF PGE2 Endorphins
IL1-R H
Histamine
5HT B2/B2
GIRK
EP
Platelets GABBAA
H1 Inhibitory

5HT
SSTR2a

M2
TTXr
Gene
(Nav 1.8/1.9)
regulation
H+ TRPV1

SP

Heat
Figure 17.2  Potential peripheral mediators of peripheral sensitisation after inflammation. The point of this figure is not so that
the reader can remember everything that happens, but to illustrate that even peripheral sensitisation, which occurs almost
every time we injure tissue, is extremely complex. The interested reader should refer to the cited text because to discuss all of
these processes here is beyond the scope of this chapter. (Artwork by Ian Suk, Johns Hopkins University, adapted from Woolf and
Costigan (1999).)

384

Pain is of the brain
Both Melzack’s ‘Neuromatrix Model’ and the International
Association for the Study of Pain (IASP) definition of
pain highlight the need to use a biopsychosocial approach
in evaluating and treating a person’s pain. They also
reinforce the concept of pain being created by the
brain as a result of multiple influences, in particular
the detection or perception of danger to the body’s
tissues. Tissue damage and the resultant nociception
is just one of these influences. As is suggested by the
IASP definition, tissue damage is neither sufficient nor
necessary for pain.
Sensitisation of the nociception/  resultant activation of voltage-sensitive channels allows an
pain system
The nociceptive system is dynamic. If the system becomes
more sensitive than usual, it often results in hyperalgesia
(things that hurt now, hurt more) and allodynia (things
that didn’t hurt now do).
Definitions
Hyperalgesia is an increased response to a stimulus
which is normally painful. Allodynia is pain caused by a
stimulus that does not normally provoke pain
(Merskey and Bogduk 1994).
Hyperalgesia and allodynia might be expected and seem
intuitively sensible after recent damage to tissue, but they
are also a predominant feature of persistent pain. It is
unlikely that the same processes are involved in hyperal-
gesia and allodynia in acute post-injury pain, and hyper-
algesia and allodynia in chronic pain.
Peripheral mechanisms
Peripheral mechanisms that increase the pain evoked by a
standardised stimulus include the presence of inflamma-
tory mediators (including proinflammatory cytokines,
bradykinin, prostaglandins), decreased circulation (which
increases the local concentration of H+ ions), the presence
of immune mediators and activation of certain genes
(Figure 17.2) (see Meyer et al. (2006) for an exhaustive
review of peripheral mechanisms of modulation). Inflam-
matory mediators are released by tissue damage and by
activation of nociceptors (neurogenic inflammation). This
sensitisation, driven by peripheral mechanisms, is called
peripheral sensitisation and the hyperalgesia that follows
is called primary hyperalgesia.
Pain Chapter 17
Spinal cord mechanisms
Second order nociceptors can also become sensitised. The
N-methyl-D-aspartate (NMDA) receptors in the dorsal
horn respond to persistent or intense stimulation by
opening channels to allow greater post-synaptic activity.
This means that the same input from the periphery will
result in greater activation of the second order nociceptor,
which means that more messages of danger to body tissue
will be sent to the brain.
Dorsal horn mechanism
NMDA receptors are important in central sensitisation.
They are normally blocked by magnesium, but prolonged
nociceptive activity and release of peptides can remove the
block and allow glutamate to bind to the receptor. The
influx of calcium into the second order neurone. This
process can lead to a change in the NMDA receptor so that
the magnesium block then becomes less effective, which
means that, next time, the sensitisation will happen more
quickly.
There are other mechanisms in the dorsal horn that can
sensitise the nociceptive system. Wide-dynamic-range
neurones in the laminae of the dorsal horn provide an
interaction of the processing for nociception and other
sensory information. This may be important in how
people describe their pain, sometimes referred to as the
‘quality’ of pain. It also provides a potential mechanism
for further sensitivity of the nociceptive system, whereby
the responses to normally non-painful stimuli, such as
touch, are now painful. This may be because the wide-
dynamic-range neurones synapse with sensitised neu-
rones. Another mechanism of sensitisation involves the
sprouting of neurones across laminae. Such sprouting
may link a non-nociceptive peripheral nerve fibre (e.g.
Aβ fibre) with an interneurone that would normally
respond to noxious stimulation. This is probably more
likely to occur after peripheral nerve injury or death.
Butler and Moseley’s (2003) Explain Pain discusses these
mechanisms in an accessible, but reasonably detailed, way.
Brain mechanisms
Supraspinal mechanisms that enhance the sensitivity
of the CNS include influences, mediated by the rostro­
ventral medulla, on the inhibitory transmission affecting
the spinal cord. Current research is looking not only at
descending modulation, but also on intracortical modu­
latory processes. Imaging studies have associated pain
processing with activity in multiple brain areas, com-
monly including the thalamus, anterior and posterior
cingulate cortex, other areas of the limbic system and
the medial prefrontal cortex (Bushnell and Apkarian
2006; Schweinhardt et al. 2008; Wiech et al. 2008). The
385
 Tidy’s physiotherapy
attributed function of these brain areas supports a role in
the cognitive modulation of pain (see below).
Neuropathic pain
The pain associated with nerve damage is known as neu-
ropathic pain and may include descriptions such as
‘burning’ or ‘electric shock’. CNS damage, such as stroke,
can result in centrally-mediated neuropathic pain that
reduces the inhibition of the nociceptive system. Peripher-
ally, damage to an axon or the myelin covering of a nerve,
can lead to spontaneous transmission of impulses from
the damaged area or the dorsal root ganglion (DRG).
This may also be driven, in part, by loss of inhibition,
specifically through alterations of chloride homeostasis
affecting gamma amino-butyric acid (GABA)-mediated
inhibition (see review of mechanisms in De Koninck
(2009) and also Sandkühler (2009)). Such damage will
usually result in hypersensitivity to mechanical input.
This sensitivity forms the basis for tests such as Tinel’s
sign – sometimes considered as an indicator of neuro-
pathic pain.
There is mounting evidence that interactions between
the immune system, the endocrine system and the auto-
nomic nervous system are important in all types of pain,
including neuropathic pain (Watkins and Maier 2000).
Pain modulation via psychological
and social influences
Anecdotal evidence that somatic, psychological and
social factors modulate pain is substantial – sport- and
war-related stories are common (see Butler and Moseley
(2003) for several examples). However, numerous ex­­
perimental findings corroborate the anecdotal evidence
(see Fields et  al. (2006) for a review of CNS mecha-
nisms of modulation and Poleshuck and Green (2008)
for a review of the impact of socioeconomic disadvan-
tage and pain).
By far the greatest research efforts in this area have
been directed towards the cognitive modulation of pain.
Experiments that manipulate the psychological context
of a noxious stimulus often demonstrate clear effects on
pain, although the direction of these effects is not always
consistent.
Attention
A large amount of literature concerns the effect of
attention on pain and of pain on attention, for example
Asmundson et al. (1997), Crombez et al. (2004), Eccleston
and Crombez (2005), Naveteur et al. (2005), McCracken
(2007), Lautenbacher et al. (2010), Verhoeven et al. (2010).
386
Despite the wealth of data, consensus is lacking: some
data suggest that attending to pain amplifies it and attend-
ing away from pain nullifies it; others suggest the opposite.
This may be explained by the existence of different modes
of selective attention (see Legrain et al. (2009) for review).
Most likely, the effect depends on the coping style of the
individual and the wider context of the experiment or
situation.
Anxiety
Anxiety also seems to have variable effects on pain. Some
reports link increased anxiety to increased pain during
clinical procedures (Schupp et al. 2005; Klages et al.
2006) and during experimentally-induced pain (Tang
and Gibson 2005), but other reports suggest no effect
(Arntz et al. 1990; Arntz et al. 1994). Relevant reviews
conclude that the influence of anxiety on pain is probably
largely dependent on attention (Arntz et al. 1994; Ploghaus
et al. 2003).
Expectation
Expectation also seems to have variable effects on pain. As
a general rule, expectation of a noxious stimulus increases
pain if the cue signals a more intense or more damaging
stimulus (Fields 2000; Sawamoto et al. 2000; Keltner et al.
2006; Moseley 2007a; Moseley and Arntz, 2007) and
decreases pain if the cue signals a less intense or less dam-
aging stimulus (Pollo et al. 2001; Benedetti et al. 2003).
There are several informative reviews on the influence of
expectation on pain (Fields 2000; Wager 2005).
The common denominator of the effect of attention,
anxiety and expectation on pain seems to be the underly-
ing evaluative context, or meaning, of the pain. That is
demonstrated by the consistent effect that some cognitive
states seem to have on pain. For example, catastrophic
interpretations of pain are associated with higher pain
ratings in both clinical and experimental studies (see
Haythornwaite (2009)). Believing pain to be an accurate
indicator of the state of the tissues is associated with
higher pain ratings (Moseley et al. 2004), whereas believ-
ing that the nervous system amplifies noxious input in
chronic pain states increases pain threshold during straight
leg raise (Moseley 2004).
Social context
The social context of a noxious stimulus also affects the
pain it evokes. For example, when men have blood taken
by a woman, it hurts less than when it is taken by another
man (Levine and De Simone 1991). The effects are varia-
ble but, again, seem to be underpinned by the underlying
evaluative context or meaning (see Butler and Moseley
(2003) for a review of pain-related data and Moerman
(2002) for exhaustive coverage of the role of meaning in
medicine and health-related interactions).

To review the very large amount of literature on somatic,
psychological and social influences on pain is beyond the
scope of this chapter. However, it is appropriate, and clini-
cally meaningful, to reiterate the theme that emerges from
that literature: the influences on pain perception, toler-
ance and report are variable and seem to depend on the
evaluative context of the noxious input.
ASSESSMENT AND MEASUREMENT
OF PAIN
Pain is an essentially personal experience, which means
measurement of pain relies on the person in pain com-
municating their experience. Therefore, any measure of
pain, including report of pain, is really a measure of pain
behaviour. Clinicians and researchers make a judgement
according to how well they think the measure of pain
behaviour might reflect pain, but, ultimately, this relies
on assumptions that as yet cannot be verified. This limita-
tion also applies to physiological measures, such as brain
imaging.
Earlier in this chapter, we argued that pain depends on
many modulating factors and can be expressed in many
ways. Moreover, we argued that pain is one output of the
brain that serves to protect the tissues. Those arguments
mean that assessment and measurement of people in pain
encompasses more than measurement of their pain. One
framework that is useful in assessment of people in pain
is the World Health Organization International Classifica-
tion of Functioning, Disability and Health (WHO ICF).
The WHO international classification
of functioning, disability and health
(WHO ICF)
This section uses the WHO ICF as a framework for assess-
ment and treatment planning of patients in pain. This
framework is advocated by the IASP (Wittink and Carr
2008). The WHO ICF focusses on how a person is func-
tioning and evaluates outcomes using the person’s actual
performance in the real-life environment. This makes it
especially useful for those patients where pain relief is not
the only, and possibly not the most important, objective.
The WHO ICF has three components: the body (func-
tion and structure); activities and participation; and con-
textual factors (e.g. environmental factors that might
influence function). Each component is classified at a level
of severity (none, mild, moderate, severe, complete) and
interactions between components are evaluated (WHO
2002). As it relates to people with pain, the three compo-
nents of the ICF broadly mirror the components of the
biopsychosocial model, which considers tissue-based, psy-
chological and social influences on pain.
Pain Chapter 17
The interview
Most therapeutic processes will start with an interview.
The interview aims to capture information about the
person in terms of the ICF. Physiotherapy interviews
have conventionally focussed on symptoms: location,
intensity, quality and temporal patterns, and signs. This
information is very important, but it is not sufficient.
According to the ICF this information relates to the body,
the biopsychosocial model’s equivalent of the tissues.
However, we advocate, as do other reviews in this area
(e.g. Gifford et al. 2006) that the interview must also
provide information about activities and participation
and contextual factors (i.e. the ‘psychosocial’), and how
these issues may interact with pain and the state of the
tissues (Goldingay 2006a, 2006b). The aim of the in­­
terview then is to identify factors from across biopsycho-
social domains which activate or sensitise the nociceptive
or pain system (see Table 17.2).
Measures and scales
Self-reporting measures
Assessing pain is a key aspect of the assessment process.
Self-reporting measures are considered the gold standard
in assessing pain intensity, location, quality and temporal
variation.
Definitions
Quality of pain refers to characteristics, such as aching,
burning, stabbing and cramping, that a patient attributes
to his/her pain.
Temporal aspects of pain commonly refers to 24-hour
behaviour of pain but might also relate to other
influences, such as menstrual cycle or seasonal changes.
Visual analogue scales (VAS) and numerical rating scales
(NRS) are most common and useful. A visual analogue
scale consists of a horizontal line, usually 100 mm long.
At each end is a term of reference for the patient, called
an anchor. The left anchor is usually ‘No pain’ and the right
‘worst pain’ or ‘worst pain imaginable’. The patient marks
a point on the line in answer to a question about their
pain and the distance from the mark to the left anchor is
used as a measure of their pain. A NRS uses numbers
instead of a line, such that 0 = ‘no pain’ and 10 = ‘worst
pain’. The VAS is probably more sensitive to change, less
vulnerable to perseveration (remembering what you said
last time and responding the same way) and more difficult
to measure. The NRS is easier to use clinically and is prob-
ably sufficiently sensitive to detect clinically meaningful
387
 Tidy’s physiotherapy

Table 17.2  Structured interview for biopsychosocial Behavioural measures

assessment
Area of Information gained
examination
Orientation Nature and location of
symptoms; patient’s story from
onset to present, expectations
of physiotherapy, questions
and concerns about problem
Previous Investigations and understanding,
intervention treatment effects, advice
received, causal beliefs
Medical history Comorbidity and effect on
function, special questions (red
flag screening), medication
Effects on function Current social and employment
and participation situation, typical day, effects on
work, restrictions on activity,
assistance required, aids and
adaptations, downtime, sleep
Although self-reporting measures are behavioural meas-
ures, they are generally considered as a separate category.
Non-self-reporting behavioural measures are useful as a
corroborator of self-reporting measures, when the patient
is unable to use the measure (e.g. children) or when the
clinician considers the patient’s report to be dubious.
Behavioural measures include observation (by a covert or
overt observer) and performance (e.g. functional, endur-
ance, speed or load tests). Full review of behavioural
measures is beyond the scope of this chapter, but the
interested reader is referred to the Handbook of Pain Assess-
ment (Turk and Melzack 2001) and Manage your Pain
(Nicholas et al. 2007) for examples.
Measures of the impact of pain
Critical to the ICF framework, and to the biopsychosocial
model, is evaluation of other factors that might be modu-
lating pain or the behavioural response to pain, or both.
Numerous measures have been devised and tested. The
following is a brief account of the most widely used and
documented.

Coping strategies Current coping strategies: active

and passive, perceived
Measuring potential impact of beliefs
consequences of change and thoughts
(e.g. increasing activity, The importance of evaluation of the threat to body tissue
exercise, pacing) has been mentioned earlier. Inherent to this evaluation is
Socio-economic Effect on finances, benefits, fear of movement and (re)injury. A large amount of
medico-legal research has investigated the role of pain-related fear
avoidance behaviour. There are many specific findings that
Effect on family Beliefs, responses, nature relate fear and catastrophic thought processes to pain
of support provided intensity, disability and self-efficacy but the principle can
Emotion Nature and extent, effect be summarised thus: people who have heightened con-
on motivation cerns about pain, its cause and its consequences, often
have a sense of helplessness and adopt a passive coping
Pre-examination Body chart, behaviour style. As a result, they have a lower criterion for a move-
of symptoms ment or activity to be considered potentially painful or
potentially injurious. They therefore avoid those move-
Reproduced from Goldingay (2006b), with kind permission of S.
Goldingay and the CNS Press. ments and activities – ‘fear-avoidance’. Avoidance of activ-
ity leads to disuse and hampers healing and recovery,
leaving the person in a vicious cycle of progressive depres-
changes [a clinically meaningful change is usually consid- sion, disuse and disability (Figure 17.3). According to the
ered to be about two points on a ten-point scale (McQuay fear-avoidance model, most people do not follow this
et al. (1997))]. path because they have a more accurate and appropriate
Several tools assess the quality of pain. A simple level of concern and thus do not tend to avoid movement
tool is a VAS, with anchors reflecting the unpleasantness and activity (Vlaeyen and Linton, 2000). See Vlaeyen and
of pain. The most widely used is the short form of Linton (2000) for a review of fear-avoidance beliefs and
the McGill Pain Questionnaire (MPQ) (Melzack 1975a). pain and Sullivan et al. (2001) for a review of catastrophic
The MPQ lists a variety of words that are grouped as thought processes and pain.
being about the sensory-discriminative aspect of pain Fear avoidance beliefs can be gauged via the interview,
(e.g. sharp, burning, intense), the affective aspect of but can be quantified via the fear avoidance beliefs
pain (e.g. punishing) or its evaluative context (e.g. annoy- questionnaire (Waddell et al. 1993) or the TAMPA
ing). There are many other measures that emphasise scale of kinesiphobia (‘fear of movement’) (Miller et al.
different aspects of pain. 1991). Data for both tools are available, from a range

388

Injury Recovery
Disuse
Depression
Disability
Avoidance
hypervigilance
Pain Confrontation
Pain related
fear
Pain catastrophising No fear
Negative affectivity
threatening illness information
Figure 17.3  The fear-avoidance model.
of clinical and non-clinical populations. Catastrophic
thought processes can also be gauged via the interview,
but can be quantified via the pain catastrophising scale
(Sullivan et al. 1995), which also has a large amount of
data available. Other measures that are psychometrically
robust and widely used in research, but are less popular
clinically, include the survey of pain attitudes (Jensen
et al. 1987), the pain beliefs and perceptions inventory
(Williams et al. 1994), and the pain anxiety symptoms
scale (McCracken et al. 1992).
What about the clinician’s thoughts
and beliefs?
There is some evidence that the clinician’s thoughts and
beliefs about pain modulate the effect of their treatment.
For example, researchers undertook a placebo-controlled,
double blind study of fentanyl (a powerful analgesic) during
wisdom teeth removal (Gracely et al. 1985). Although all
patients had the same likelihood of receiving fentanyl, the
researchers told some of the dentists that the patient
would not receive fentanyl. This was a lie. When the
clinician thought that the patient might get fentanyl (which
was true), pain dropped by two points after the placebo
injection. When the clinician thought that the patient
could not get fentanyl (which was a lie), pain increased
by five points after the placebo injection. This difference
(~7 points) was owing to the belief of the dentist!
Other studies have shown that the fear-avoidance
beliefs of people with back pain are similar to those of
their rheumatologists (Poiraudeau et al. 2006) and that
rheumatologists’ fear avoidance beliefs affect the decisions
they make about their patients’ management (Coudeyre
et al. 2006).
Pain Chapter 17
Self-efficacy
Self-efficacy is the belief an individual has about their
ability to perform a task using their current resources.
Because self-efficacy depends on appraisal of the demands
of a particular task and of the individual’s own capacity to
meet them, self-efficacy depends on evaluative factors
about pain and injury. Self-efficacy is therefore affected by
inappropriate or inaccurate appraisals. However, self-
efficacy can be assessed as a separate construct that is
sensitive to treatment and is closely related to function
(Nicholas et al. 1991). For more information on self-
efficacy as it relates to pain assessment and management
see Nicholas (2007).
Red, yellow, blue and black flags
Red flags are those signs and symptoms that should alert
the physiotherapist to seek other specialist opinion. A
useful resource for patients with back pain is Greenhalgh
and Selfe’s Red Flags, which includes a focussed discussion
(Greenhalgh and Selfe 2006).
The ‘yellow’ flags are signs, symptoms, beliefs and atti-
tudes that are thought to increase the risk of acute pain
developing into a disabling chronic pain condition. This
approach was devised to assess for risk of pain-related
disability in people with acute (recently occurred) back
pain. Increasingly, it is being used in people who report
pain in other anatomical locations. The purpose of assess-
ing in this manner is to identify patients who have
unrealistic and unhelpful beliefs about their pain and
prognosis (Kendall et al. 1998). While there are standard-
ised questionnaires available, carefully selected questions
can also be used effectively during interview (Watson
and Kendall 2000).
As an adjunct to yellow flags, a more comprehensive
consideration of occupational factors can be achieved by
considering assessment of ‘blue’ and ‘black’ flags. ‘Blue’
flags would be indicated if a person has work-related con-
cerns about how he/she as an individual might be impeded
in returning to work. For example, there may be a percep-
tion that the managers do not want this person to return
to work. ‘Black’ flags are indicated if work processes and
policy (which influence all workers) impede the person
returning to work. An example of this would be where
an employer does not have any occupational health pro-
cesses in place, such as workplace assessment or return to
work plans.
Measures of functional limitation
and disability
There are a large number of self-report tools that aim to
measure the functional impact of a person’s pain. A large
proportion of those tools concern back pain [e.g. the
Roland Morris disability questionnaire (Roland and
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 Tidy’s physiotherapy
Morris (1983)) and the Oswestry questionnaire (Fisher
and Johnston (1997))] or neck pain (e.g. the neck disabil-
ity index (Vernon and Mior (1991)). These tools are widely
used and a large amount of data exists from patient and
non-patient populations. There are also disability ques-
tionnaires that are not anatomically focussed, for example
the task-specific tools whereby the patient selects a task or
activity that they are unable to perform because of pain
and rates their ability to perform that task over the course
of treatment. An advantage of such a tool is that it can be
used with different populations. A disadvantage is that it
makes direct comparison between treatments or between
patients difficult.
A recent review explored a range of pain assessment
instruments with the purpose of identifying people at
risk of developing persistent pain (Grimmer-Somers et al.
2009). The review identified 16 assessment tools suitable
for use in primary health settings. This is one of many
attempts to identify assessment strategies that screen
those at risk of developing long-term pain and disability.
Early identification of ‘modifiable obstacles to recovery’
(Watson et al. 2010) has been an underachieved aim,
despite the development of clinical evidence-based guide-
lines. Concepts of ‘acute’ and ‘chronic’ pain may be
unhelpful here, as multi-dimensional pain assessment
may not occur for several weeks post-injury. To ensure
early risk identification, pain assessment should always
aim to be multi-dimensional, even in instances of acute
injury with frank tissue damage.
It should also be noted that novel treatment tech-
niques (see later) drawn from revolutionary knowledge
about the plasticity of the brain also demand novel
assessment techniques. Harman (2000) wrote about the
impact of plasticity on assessment and treatment of
pain more than a decade ago and more recently Flor and
Moseley and colleagues have assessed for asymmetries
of brain representations to guide their interventions
(Moseley 2007b; Flor 2009; Moseley and Wiech 2009,
2010; Moseley et al. 2009). While it is impractical to be
scanning the brain of people in clinical practice, more
practical assessment techniques using computer or card-
based images may be indicators of the central processing
asymmetries.
MANAGEMENT OF PAIN
European guidelines for the management of low back
pain, based on the best available research evidence, have
been published. Included are guidelines for people with
pain of recent onset, for people with pain that is persistent
and for people with pain that is threatening to lead to
ongoing disability (van Tulder et al. 2002; Airaksinen
et al. 2004). Elements of these guidelines will be presented
below (see Airaksinen et al. (2006) for application in
390
physiotherapy). It is important to recognise that these are
specific to low back pain, but in the absence of guidelines
they may also provide a basis for the management of other
painful conditions.
Promoting optimal function with
reference to WHO ICF
By using the ICF framework, the range of factors influenc-
ing a person’s function will be considered as treatment
targets. For example, the physiotherapist may recognise
that a person with back pain has restricted movement. If,
when considering restriction in activities and participation,
it is also identified that the person is afraid of walking up
the front stairs at home because they do not have a rail,
the focus of treatment might change to incorporate this
context. Thus, the clinician must reason as to the most
achievable goal: addressing the restriction in movement
may resolve the fear about the stairs. Alternatively, the
person may need a handrail. Optimally, the physiothera-
pist assists the person in becoming confident to climb
stairs without a rail. This will lead to generalisation to
confidence in other environments. The important issue is
that focussing on body structure and function alone will
not guarantee that function is restored, and using the ICF
prompts clinicians to explore and resolve other barriers to
rehabilitation.
Clinical note
Warning: You can make things worse.
These behaviours of the clinician have been linked to
worse outcomes (Kouyanou et al. 1998):
• over-investigation;
• over-treatment;
• unhelpful treatment;
• disconfirmation of pain;
• unhelpful advice.
Deactivating/desensitising  
the nociceptive system
While many traditional approaches to pain support
peripheral treatment to the musculoskeletal system and a
focus on deactivating pain systems there is an increased
need to consider treatments that promote desensitising
mechanisms. Indeed, it may be that many so-called mus-
culoskeletal treatments, such as manipulation and mobi-
lisation of joints, may be better described as neurological
treatments. Assessing the sensitisation (i.e. via assessment
of state and structure) of the nervous system then becomes

the starting point for making sense of a person’s pain and
for identifying the best intervention (Jones 2007). In cases
of persistent pain, innovative treatment approaches have
exploited knowledge of sensitivity and brain activity for
best results. The following discussion will lead from inter-
ventions where the local site of injury is believed to be the
target, to more complex interventions where the effects of
treatment are likely to be diverse.
Addressing peripheral mechanisms
of nociception
Removing the noxious stimulus is often the primary moti-
vation of the person with pain and where this is not pos-
sible it becomes the clinician’s role. As such, reducing
high threshold mechanical, chemical or thermal stimuli
should deactivate the primary afferent activity. However,
the consequences of cell damage establish at the least,
peripheral sensitisation as a normal and necessary sequel
to injury. With the nervous system in this state, normally
subthreshold stimuli may now trigger nociceptor activity.
For example, normally innocuous biomechanical defor-
mation may now lead to pain; indeed, this is the basis for
using palpation to detect tissue damage.
Inflammation is the main cause of peripheral sensitisa-
tion, so limiting inflammation should help desensitise
the nociceptive system. Normally, the body’s response
to injury, which includes motor, immune and vascular
responses as outlined earlier, limits the period of in­­
flammation. In addition, the conventional response to
inflammation has been to initially cool the area, compress,
elevate and immobilise it (rest, ice, compression and ele-
vation (RICE)) and as healing progresses engage in a
gradual increase in movement and activity.
There are also pharmacological means to reduce or
limit inflammation. The broad class of drugs that are
most often used to reduce inflammation are aptly called
‘anti-inflammatories’, although there are three important
considerations. Firstly, the clinician must evaluate the
relative importance of inflammation in initiating the
healing process. This depends on sound knowledge of
Awareness of analgesics
In some places the physiotherapist has a prescribing role.
However, it is more common for physiotherapists to liaise
with other healthcare professionals to ensure effective
pain relief is available and administered to the patient.
Different analgesic drugs act differently, stay in the
bloodstream for different durations and have different side
effects. It is important that physiotherapists know about
the analgesics which are prescribed to the patients with
whom they work.
Pain Chapter 17
biological mechanisms associated with healing, nocicep-
tion and pain. Secondly, the site of analgesic effect of
anti-­inflammatories has not been established – it is un­­
likely that their only effect is at the tissues. Thirdly, even
if their main effect is at the tissues, they cannot be
confined to the target area because they are administered
systemically (e.g. orally, by injection) or transported
remotely in the circulation (e.g. topical agents). This is
why most drugs have unwanted side effects. Thus, advice
about any drug should not be made without appropriate
expertise and medico-legal jurisdiction.
An important method by which inflammation and its
effects are normally limited is movement. Movement pro-
motes blood flow, oxygen supply, waste product removal
and appropriate forces to guide healing. One common
barrier to movement is the conscious decision of the
person to not move – a decision enhanced by the increased
nervous system sensitivity. Such decisions depend on the
person’s evaluation of the importance and risks of doing
so, and this is where the clinician can be key to normal
recovery – effectively removing the barriers to abnormal
recovery. Of course, strategies that enhance a person’s
motivation to move should be considered in light of a
sound understanding of tissue healing and within a clini-
cal reasoning framework. This includes determining the
stage of healing and therefore the relative vulnerability of
affected tissues – at times this is counter to the pain report
of the patient. We will revisit motivation later when we
focus on central mechanisms.
Addressing spinal mechanisms
of nociception
According to the ‘Gate Control Theory’, interactions of
primary afferent and second order neurones in lamina II
can modulate the transmission from nociceptors (Melzack
and Wall 1965). While the theory is more than 40 years
old, and the understanding of neurophysiology has devel-
oped further, the basic premise that sensory information
is received and modified in the dorsal horn by competing
stimulation and descending information holds true.
Thus, there are two broad mechanisms that can desen-
sitise spinal nociceptive neurones: shifting the balance of
descending modulation toward inhibition and providing
novel peripheral input that activates Aβ neurones. The
former can be promoted by reducing the perceived threat
and perceived vulnerability, i.e. make the person feel safe.
For example, listen to them, make them comfortable (as
possible), speak to them nicely and respect them. The
latter can be utilised in varying degrees of sophistication,
from ‘rubbing it better’ to transcutaneous electrical nerve
stimulation (TENS), which was developed as a direct
application of the gate control theory (Melzack 1975b).
There is good evidence that TENS reduces acute pain, but
not chronic pain (McQuay et al. 1997).
391
 Tidy’s physiotherapy
Elements of other comforting treatments, such as thera-
peutic ultrasound, heat therapy and massage therapy, may
also contribute to spinal desensitisation by making the
person feel safe and by providing novel peripheral input.
This highlights that benefits seen with many treatments
can potentially be attributed to diverse mechanisms,
including those associated with placebo. Where these ben-
efits do not clearly align with the theory supporting the
treatment modality, they are referred to as non-specific
treatment effects and perhaps reflect complex brain mech-
anisms. It is the clinician’s responsibility to critically
analyse the benefits of a treatment modality and recognise
which elements are influencing the observed outcomes.
Systematic reviews and clinical guidelines can be instruc-
tive in this analysis (Ottawa Panel 2004; French et al.
2006; Furlan et al. 2008).
Addressing brain mechanisms of
nociception and pain
The mechanisms by which nociception and pain can be
decreased by the brain are not well understood. However,
the principle, which depends on the conceptualisation of
pain as the conscious correlate of the implicit perception
of threat to body tissues (see Moseley (2007a) for a review)
is well understood. We argued earlier that pain depends
on evaluative factors, which means that any input that
alters the brain’s evaluation of threat to body tissue should
modulate pain. In the same way that evaluative factors
should change pain, they should also change descending
modulation of nociceptive circuits and, therefore, the state
of the nervous system, i.e. its sensitivity. Comprehensive
coverage of the strategies that are advocated within the
literature is beyond the scope of this chapter, but it is
appropriate to mention some of them.
Cognitive-behavioural therapy
Cognitive-behavioural therapy probably began as a com-
bination of cognitive therapy and behavioural therapy.
Cognitive therapy focusses on identifying, challenging and
replacing cognitions (thoughts, beliefs and emotional
Clinical note
The psychological construct of self-efficacy is likely to be
important. Self-efficacy is the belief someone has about
his/her ability to perform a task using current resources.
Physiotherapists tend to be good at promoting activities
that enhance self-efficacy, although they may not always
recognise it. Education, verbal encouragement,
promoting mastery of a task and creating of groups of
similar people for activity all have the potential to
improve self-efficacy.
392
processes) that might be contributing to the patient’s pain
or functional limitations, perhaps via fear or avoidance of
movement and re-injury, or simply by elevating the per-
ception of threat to body tissue. Once identified, thoughts
and beliefs can be challenged by pointing the patient to
material, experiences or situations that contradict that
belief. Ultimately, unhelpful thoughts and beliefs need to
be replaced by more accurate or helpful ones.
Behavioural therapy was first applied to management of
people in pain several decades ago (Fordyce 1970, 1973).
In that work, operant conditioning principles guided treat-
ment such that behaviours consistent with decreased pain
or disability were reinforced and those consistent with
increased pain or disability were not.
Modern cognitive-behavioural pain management is far
wider in its application than cognitive and behavioural
therapy combined. There are many strategies that are
incorporated into a cognitive-behavioural pain manage-
ment approach. Cognitive-behavioural principles within
the context of physiotherapy practice are comprehensively
presented in Nicholas and Tonkin (2004).
Explaining pain biology
Intensive education about the biology of pain is one way
in which unhelpful cognitions about pain, injury and
activity can be challenged and replaced. Explaining pain
biology in detail has been shown to change beliefs and
attitudes about pain, movement and activity (Moseley
et al. 2004), increase pain threshold during relevant tasks
(Moseley 2004) and, combined with movement-based
physiotherapy, decrease pain and disability in the long
term (Moseley 2002, 2003). By educating someone effec-
tively, the person is given a new perspective on which to
base thoughtful action. This involves acceptance by the
person that the information he/she had before has been
superseded by the newly presented information. Patients
are given new concepts that include neural sensitivity and
central processing to replace old ones about tissue vulner-
ability. The material that is used to explain pain is pre-
sented in the aptly named book Explain Pain (Butler and
Moseley 2003).
Motivation
Strategies that are used to enhance motivation include
reassurance and education (Butler and Moseley 2003;
Moseley et al. 2004), training diaries and overt monitor-
ing of self-initiated rehabilitation (Moseley 2006a),
challenging unhelpful cognitions and offering new ones
(effectively cognitive therapy principles), careful and
graded exposure to movements or activities of which
the patient is fearful (Vlaeyen and Linton, 2000) and
reinforcement of helpful behavioural responses (effec-
tively, behavioural therapy principles (Nicholas and
Sharp 1997)).

Clinical note
Motivation is sometimes used to describe the opposite to
laziness. However, it should be considered as a term that
describes the outcome of a person’s evaluation of
influences on the decision to act or not. A challenge for
the clinician is to help resolve barriers to action and
enhance resources. Together, these might swing the
balance and enhance a person’s motivation.
Relaxation
Relaxation is best performed at times when a person is still
in control of his/her pain but feels that it is worsening.
Often, it is targeting the emotional response to pain or the
expectation of pain. As such, it is important to ensure
patients have a strategy that can be used at such times,
preferably without interruption to any task that they might
be doing. Physiotherapists often prefer muscular hold-
relax techniques but teaching more meditative techniques
is perhaps more valuable, as it can be applied in many
different contexts and environments.
Clinical note
Relaxation should be seen as a skill that needs to be
practised. A useful technique is described by Nicholas
(2007). First, there is a focus on breathing and
‘loosening’ up with exhalation. Second, the person is
encouraged to imagine the tension leaving the muscles
with each exhalation. The third step involves linking the
relaxation to a word the person says to him-/herself (such
as ‘relax’) and an image of a peaceful scene. The word
and the image may facilitate further relaxation, but
through repetition they will also become triggers to
relaxation (via classical conditioning). A person is then
able to use the word or the image to quickly bring on a
relaxed state.
Pacing
Pacing is essential for people who have persistent pain and
find it difficult to plan ahead because they are unsure of
how their pain might affect activity. An example is where
a person is highly active on days when the pain is mild,
but inactive on days when the pain increases. Sometimes
called the ‘boom or bust cycle’, it prevents a person from
attending regular employment, as well as interfering with
planning of social activities.
Resolution of the ‘boom or bust cycle’ can be achieved
by pacing activity to a level that the person knows they can
Pain Chapter 17
achieve, despite pain. When pain is increased the person
should attempt to use strategies, such as thought challeng-
ing and relaxation, to increase activity to the planned level.
When the pain is mild, the person must resist increasing
activity above the planned level.
Clinical note
It is useful when giving exercise advice to a person with
persistent pain or a sensitised nervous system to consider
the use of exercise quotas; that is, to use a pre-
determined duration or number of repetitions as a limit
to activity, rather than using pain or discomfort as the
guide. This will reinforce the message that activity is
beneficial and that pain is not a sign of ongoing
damage.
Setting quotas requires establishing a baseline of
tolerance for the exercise or activity. The first quota
should be below this (80% of baseline) to ensure the
person is confident of achieving it. Then the person
should work at gradually increasing activity past the
baseline towards a more desirable level. It is essential
that the person plans the next quota in advance. Initially,
this may be just the day before, then as he/she becomes
more confident in his/her activity levels, he/she can plan
the week in advance.
Setbacks may occur and sometimes quotas may not be
achieved. In such cases, the person should be
encouraged to use active coping strategies to try to
improve performance. If this fails the quota may need to
be slightly decreased. It is important to assist the person
with their self-motivation by providing successful
experiences and it should also be clear to the person
that the activity is the focus not the pain (Nicholas and
Tonkin 2004).
When a person first comes to physiotherapy, the indi-
vidual will have a sense of the level of activity they can
achieve. That sense may be exaggerated or, more likely,
under-estimated. A more realistic level may only be
achieved after education, successful behavioural experi-
ments and reconceptualisation. Optimum levels of activity
will be achieved when the skills of thought challenging,
relaxation and pacing are well developed and consistently
applied.
Graded activity versus graded exposure
Physiotherapists will often employ a graded activity pro-
gramme to help someone return to full function. The
assumed benefits of this are generally considered to be
physical, i.e. the person is getting gradually stronger or
more flexible and is therefore able to do more. Another
393
 Tidy’s physiotherapy
benefit is confidence or self-efficacy. Graded activity can
enhance self-efficacy by allowing the person to achieve
successful performance at increasingly more difficult
levels. Assessment of performance should always include
these influences; changes in performance should not
just be considered in terms of strength and range of
movement.
Further to this is the role of fear or phobias on confi-
dence and on performance. As previously mentioned, fear
avoidance behaviour can lead to severe disability. An effec-
tive psychological strategy that has been employed to
reduce fear is graded exposure. This involves first finding
a baseline that does not elicit fear and then gradual expo-
sure to increasingly more fearful experiences that have
been identified and ranked by the patient. If someone is
fearful of pain on movement then the experiences often
will involve physical activities. For example, someone with
complex regional pain syndrome in his/her right upper
limb may start with imagining the hand being touched by
someone else. The person may then progress to stroking a
rough texture, to shaking hands with someone, to lifting
a bag full of shopping.
By integrating graded exposure and graded activity, the
physiotherapist is likely to help the person to reach physi-
cal goals that relate to strength, range of movement and
function, as well as psychological goals that relate to
decreasing fear and increasing self-efficacy, participation
and function.
Targeting cortical representations   This chapter attempts a monumental task – to synthesise
of the body
Emerging data suggest that there may be another strategy
by which supraspinal mechanisms of nociception/pain
can be desensitised. That strategy relates to the one way
in which the brain changes when pain persists – altera-
tions in the representation of the affected part in primary
sensory cortex (S1) (see Flor et al. (2006) and Moseley
(2006b)). The mechanisms by which this occurs may be
activity-dependent, but may also relate to inhibition of
non-noxious sensory input at the thalamus (Rommel et al.
1999). That S1 representation changes cause pain is argued
(Harris 1999) but not empirically demonstrated (Moseley
and Gandevia 2005). Notwithstanding, it is clear that nor-
malisation of S1 representation is associated with reduced
pain (Flor 2003; Maihofner et al. 2004; Pleger et al. 2005),
that tactile acuity relates to pain and to S1 representation
changes (Flor 2003), and that training tactile discrimina-
tion increases tactile acuity and reduces pain – at least in
some patient groups (e.g. phantom limb pain (Flor et al.
2001) and complex regional pain syndrome (Moseley and
Wiech 2009). The role of normalising S1 representation
is yet to be established; however, it seems reasonable
to suggest that a role may emerge (see Flor (2009) for
further reading).
394
Clinical note
There is a large amount of data that shows (i) you can
improve tactile acuity via training; (ii) that when you
improve tactile acuity, you do so by altering the firing
properties of neurones in the brain; and (iii) improving
tactile acuity is therefore associated with altered
representation of the trained body part in the brain.
There seem to be several important aspects to training
tactile acuity.
• Sensory stimulation: the body part in question must
be stimulated.
• Attention: training is more effective if the subject
attends to the input. A useful way to ensure that this
occurs is to provide a task that requires that they
attend. This is what Flor and colleagues did (Flor et al.
2001) and what Moseley and colleagues did (Moseley
and Wiech 2009). In those studies, patients were
required to discriminate between stimuli of different
types and at different locations.
• Gaze direction: training is better if the subject directs
his/her head toward the body part being stimulated.
• Visual input: training is better if the subject can see
the body part being stimulated.
LIMITATIONS AND OPPORTUNITIES
volumes of pain research from basic and clinical sciences
into a digestible package appropriate for clinical physi-
otherapy practice. The complexity of the human experi-
ence, which is exemplified in the human experience of
pain, means that this chapter can only provide an intro-
duction. We considered it most important that the reader
conceptualises pain in a manner that is consistent with
what is known about human biology. Entire books have
been written about the peripheral nociceptor and entire
libraries could be filled with books on the spinal cord
and brain, so we have attempted to convey what we think
is sufficient evidence for adopting a certain way of think-
ing about pain. We think the following points are justified
on the basis of the available research and can be con-
sidered the key ‘take-home messages’.
• The science shows clearly that pain depends on the
brain’s appraisal of threat to body tissue. Nociception
is a very important informant in this regard, but it is
neither sufficient nor necessary for pain.
• Many factors from sensory, psychological and social
domains modulate pain.
• The effect of these factors can be understood via the
principle that pain is the conscious correlate of the
implicitly perceived threat to body tissues.

• It is possible to identify and estimate the impact of
various factors on pain by questioning the patient
carefully in the interview and by using self-report
questionnaires.
• Once issues have been identified, they should be
addressed in management.
• Physiotherapists have a wide range of skills and
resources with which to deactivate and desensitise
the nociception and pain systems at various levels
– tissue, spinal and brain.
• This chapter is a starting place. We have referred the
reader to more comprehensive sources of information.
When we evaluate the large amount of research in
pain sciences and management, two things seem clear.
Firstly, the field is progressing rapidly. With a better
understanding of the complexity of pain we are encounter-
ing new opportunities for pain management. Secondly,
physiotherapists are ideally trained and resourced to
be intimately involved with these new developments –
physiotherapists, perhaps more than any other profes-
sional group, can access every domain that contributes to
pain, from the tissues to the society.
CASE STUDY: INFLAMMATORY
PHASE (IMMEDIATE POST-INJURY   Physiotherapy appointment
TO 2–5 DAYS)
Introduction
Daniel slipped and fell stepping off an icy footpath on
his way home from university. He hurt his ankle and,
with the help of his friends, attended the hospital emer-
gency department. A decision was made to X-ray the
ankle and, as no bony injury was detected, a diagnosis of
a grade 2 ankle sprain of anterior talofibular ligament
(ATFL) was made. They provided him with crutches, fitted
an elasticised tubular bandage and made an appointment
for physiotherapy.
The physiology of pain
Activation of the nociceptive system
As Daniel’s ankle was forced into inversion the high
threshold mechanical force would have triggered noci­
ceptor activity. As his body parts were deranged and
uncontrolled as he slipped and fell, the potential threat
to tissues would be enhanced and reflected in the
central processing of the mechanical stimuli. Once injury
to the tissue occurred, substances would be present in
the tissues that directly trigger the nociceptors (chemical
stimulus).
Pain Chapter 17
Sensitisation of the nociceptive/pain system
Along with the inflammation response, sensitising
substances promote transmission of nociceptive informa-
tion, enhancing normally painful stimulation (peripheral
sensitisation/primary hyperalgesia) and, possibly, via
spinal mechanisms, contributing to increased sensitivity
to areas adjacent to the site of injury (central sensitisation/
secondary hyperalgesia) and even creating areas that have
a painful response to stimuli that is normally not painful,
for example touch (allodynia).
Pain modulation via psychological
and social influences
Daniel was obviously anxious enough about his ankle
to seek immediate medical advice – with assistance from
his concerned friends – so it could be assumed attention
to the injured part and the social context may promote
enhancement of his pain experience. Although as stated
in the body of the chapter there is some contention
about the role of attention. The medical staff’s decision
to refer to X-ray may have also provoked some anxiety,
although the result of no bony injury should have been
reassuring.
 
(day 2 post-injury)
Assessment and measurement of pain
From the initial interview (refer to Table 17.2)
• Daniel is 19 years old with no previous history of
lower limb problems (personal factors).
• He tells you that his ankle swelled up ‘like a balloon’
and he experienced pain on the lower lateral border
of fibula and was unable to weight-bear for more
than four steps.
• He currently complains of pain on the lateral aspect
of his foot and ankle (hyperalgesia) which worsens
with movement, weight-bearing and when the quilt
on his bed touches it at night (allodynia) (body
function).
• He is unable to wear normal footwear because
of the swelling (activity/participation; body
structure).
• He lives with his parents, who are now going to have
to drive him around, and is currently unable to
undertake his daily routine, work part-time in a bar
or play football for the university team (activity/
participation).
• He tells you he is already ‘fed up’, that he can’t do
anything and is keen to ‘get back to normal as soon
as possible’. He is particularly anxious about losing
wages from his part-time job, as he is unable to
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 Tidy’s physiotherapy
stand for long periods of time (personal/
environmental factors).
• The hospital medical staff prescribed anti-
inflammatory medication and encouraged the use of
a recommended daily dose of paracetamol. He
reports that this has been mostly effective.
• His VAS for pain intensity measures 40 mm for the
last 24 hours and is currently 55 mm. His last
analgesia was taken two hours ago. When he tries to
weight-bear he describes the pain as much worse,
measuring 95 mm on the VAS.
• His VAS for pain unpleasantness for the last 24
hours measures 65 mm and is currently 65 mm. The
difference in this measure compared with the pain
intensity measure may reflect that there is an
emotional influence on his pain, perhaps related to
his frustration about the situation.
In this, and subsequent appointments, it is important
to ensure Daniel does not have any co-pathology that
might have predicated the fall or tissue damage (see red
flags) or any unhelpful beliefs or expectations about his
condition (see yellow flags/ blue and black flags).
You undertake full physical examination and your find-
ings include:
• non-weight-bearing on affected lower limb;
• significant swelling of lateral ankle extending into
anterolateral foot;
• local bruising around lateral malleolus;
• movement is limited by pain and swelling, especially
inversion;
• tenderness is present with palpation of lateral ankle,
especially the area corresponding to ATFL.
Your observation is consistent with a grade 2 ATFL ankle
sprain (Brukner and Khan 2006).
Management of pain
The aims of treatment of Daniel’s pain are to:
• educate about his injury, pain and physiotherapy, i.e.
establish ‘helpful’ beliefs/expectations;
• control the inflammatory process (RICE and
non-steroidal anti-inflammatories (NSAIDs)), i.e.
reduce concentration of sensitising chemicals;
• control and reduce swelling, i.e. the increase in
sensitivity, the mechanical force of distension or
compression of tissues caused by swelling may be
triggering nociception;
• encourage early protected movement, including
weight-bearing, i.e. to promote self-efficacy, reinforce
pre-existing synaptic activity and mobilise tissues/
swelling.
In the acute stage, pain is a reasonable guide to safe
activity. This is because the increased sensitivity (hyperal-
gesia) means that transmission of nociceptors is initiated
396
well before the risk of tissue re-injury. It should be noted,
however, that analgesics can confound this.
CASE STUDY: THE REMODELLING
PHASE (FROM THREE WEEKS TO
TWO+ YEARS)
Introduction
Sally hurt her back while mopping the floor at work four
months ago. She couldn’t go to work the next day and
made an appointment with the local doctor. The doctor
gave her some NSAIDs and told her to rest for three weeks.
After three weeks, she went back to see the doctor as she
was no better; he gave her stronger analgesics and sent her
for physiotherapy.
There was a six-week waiting list to see the physiothera-
pist so Sally continued to rest as she didn’t know what to
do in the meantime.
When Sally saw the physiotherapist she was given
several simple exercises.
The exercises made her back hurt more. Sally associated
this with re-injury/ further damage so she did not keep her
next physiotherapy appointment.
The doctor has told her that if she doesn’t go to the
physiotherapy appointments she isn’t going to get better.
Reluctantly, she returned to physiotherapy.
The physiology of pain
Activation of the nociceptive system
It could be that four months ago, there was a significant
mechanical stimulus that triggered transmission in
nociceptors and possibly a local inflammatory reaction.
However, as she is now reporting pain with even simple
exercises, it can be expected that the sensitisation of the
system is the important factor here. Chemical stimuli,
especially changes to tissue pH, may trigger nociceptors
where movement is restricted, affecting blood flow and
nutrition.
Sensitisation of the nociceptive/pain system
Presuming that some tissue damage occurred during the
mopping incident – although tissue damage is not required
for someone to feel pain – then the inflammation process
would now be well and truly complete. Unless of course,
there has been a re-injury, or a comorbidity such as dia-
betes, that prolongs tissue healing. If there is no inflam-
mation then there are no sensitising chemicals and no
swelling is likely. Enhanced spinal processing of nocicep-
tor and somatosensory information may still be occurring

owing to descending influences (see below). Also, pro-
longed afferent activity may promote transmission at
spinal NMDA receptors – this may be in the form of pro-
tective muscle spasm.
Pain modulation via psychological
and social influences
Sally has been unable to work for four months and
could be expected to be feeling quite helpless. It can be
expected that she doesn’t trust her back and may feel it
is at risk of injury. She may also avoid movement activi-
ties (kinesiophobic) because she is anxious about the
pain. Her parents may be inadvertently reinforcing this
avoidance if, through their assistance, they are reinforcing
the ‘helpless’ message (reinforcing ineffective behav-
iours). According to the concept of pain promoted in this
chapter, Sally’s sense of vulnerability is likely to reduce
the inhibition of nociceptor transmission and promote
mechanisms – via spinal and supra-spinal processes
related to attention, expectation and mood – that reduce
the activation threshold of the nociceptive system. As
such, her pain is still ‘real’ pain but is likely to have less
obvious peripheral triggers. Altered cortical representa-
tions may also have established across this time of rela-
tive inactivity.
Physiotherapy appointment   • tenderness on palpation generally and especially
(four months post-injury)
Assessment and measurement of pain
From the initial interview (refer to Table 17.2)
• Sally is 28 years old and a single mother with two
young sons, aged five and seven years (personal
factors).
• Owing to her pain, Sally has stopped all housework
and her parents are having to do all of the shopping
and care for the children, especially after school
(activity/participation).
• Sally finds that resting from her normal activities was
making her pain easier but now she is feeling weak,
easily short of breath and generally very stiff and still
experiencing pain (body structure/ function).
• She finds when her pain is less she does much more
activity but then needs two days rest to recover
(body function; activity/participation).
• She tearfully tells you that she is worried about her
future, she is unable to meet the rent payments, she
has lost her job and is only sleeping 3–4 hours per
night (personal/ environmental factors; body
function).
• She is unclear about what is happening in her back
and why the pain is going on so long. She asks you
if you think a scan would help as she thinks she isn’t
Pain Chapter 17
being taken seriously by her doctor (personal
factors).
• Her VAS for pain intensity measures 60 mm for the
last 24 hours and is currently 65 mm. Her last
analgesic was taken two hours ago. She describes her
worst pain when she bends forwards, measuring
100 mm on VAS.
• Her VAS for pain unpleasantness for the last 24
hours measures 80 mm and is currently 75 mm.
Sally’s higher rating for the unpleasantness of
pain may relate to the affective component of
pain and reflect beliefs about persisting or
worsening tissue damage, or might be related
to depressed mood.
As part of the assessment process, it is crucial to ensure
Sally does not have any co-pathology. This includes sinis-
ter pathologies (see red flags). The information provided
from the interview indicates evidence of factors that
inhibit recovery and return to work (see yellow flags/ blue
and black flags).
You undertake full physical examination and your find-
ings include:
• posterior pelvic tilt with flattened lumbar spine;
• tightness in hip flexors/abdominals/latissimus dorsi;
• slow and rigid gait for age;
• movement of upper and lower limbs is limited by
pain in back;
lumbar spine;
• high body mass index.
Management of pain
The aims of treatment/management of Sally’s pain are :
• to educate about her injury, the phases of healing,
pain and physiotherapy, i.e. establish ‘helpful’
beliefs/expectations;
• to encourage effective use of medication on a
‘time-linked’ basis;
• to encourage movement, including bending, i.e. to
promote self-efficacy, redress synaptic activity and
normalise mapping of brain representations and
control;
• to incorporate graded motor imagery and tactile
discrimination techniques as appropriate;
• to practise strategies for upgrading and predicting
consistent levels of activity, such as quota-setting,
pacing, challenging of unhelpful beliefs, relaxation/
distraction;
• employment of self-applied modalities, such as soft
tissue stretching, heat and TENS, as supported by
best research evidence, with advice to avoid
dependence;
• vocational training.
397
 Tidy’s physiotherapy

It is not reasonable to use pain as a guide during the
remodelling phase in this case because the healing process
has achieved tissue integrity – movement is safe and the
increased sensitivity (hyperalgesia) means that pain is
felt at low, ineffective activity levels. Pain still needs to be
respected. Sally should be made to feel safe at every
opportunity, while encouraging her to set her own goals
and challenges for improvement in activity level, despite
pain. It is essential that progressions in her level and type
of activity should be to a level and within a timeframe that
she feels comfortable with.

ACKNOWLEDGEMENTS

GLM is supported by the National Health and Medical Research Council of Australia, ID 579010.

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 Chapter
Acupuncture in physiotherapy
Andrew Bannan
A BRIEF HISTORY OF ACUPUNCTURE
While it is widely assumed that acupuncture originated in
China, some evidence of its existence in central Europe
was discovered in 1991 when a frozen corpse, subse-
quently named Oetsi the iceman and estimated to be the
remains of a 5000-year-old male, was found with tattoos
largely consistent with acupuncture points (Dorfer et al.
1999). Furthermore, the location of these points appeared
consistent with an acupuncture prescription for the treat-
ment of the lower back and abdominal conditions which
study of the remains would suggest this man suffered from
(Moser et al. 1999). In China, the discovery of sharpened
bones and stones (known in Chinese as bian or bian shi)
dating to the Neolithic period, or 8000 years ago, has been
suggested to be evidence of the practice of a form of acu-
puncture, but it is more likely that these sharpened tools
were, at least initially, used for blood-letting and the drain-
age of abcesses (Ma 1992; Basser 1999; Unschuld 1985).
It is thought that acupuncture practice may well have had
origins in the once near-universal practice of medical
blood-letting which began in Ancient Greece and was used
to remove what was diagnosed as stagnant blood, a
description sometimes used in traditional Chinese medi-
cine to describe the state of qi flow in ill health which may
be beneficially affected by needling.
Regardless of its specific origins, the classic text Huang
Di Neijing (translated as Inner Classic of Huang Di) intro-
duced the practical and theoretical foundations of what
subsequently became known as acupuncture (Ramey and
Buell 2004). Commonly referred to as The Yellow Emperor’s
Classic of Internal Medicine, this text is judged to be approx-
imately 2000 years old and is presented as a series of
questions and answers between the then Emperor, Huang
Di and his physician Chi-Po (Ma 1992; Kaptchuk 2002;
White and Ernst 2004; Baldry 2005). Over the centuries
acupuncture developed and was used alongside herbal
medicine, diet, massage and the use of heat therapies,
18 
including the burning of moxa or moxibustion in China
(Ma 1992). A sixteenth century acupuncture specialist cast
bronze figurines to assist in the location of acupuncture
points (Ma 1992). It was not until 1601 that the publica-
tion of The Great Compendium of Acupuncture and Moxibus-
tion by Yang Ji-Zhou formulated what we now recognise
as acupuncture practice detailing 361 points (Kaplan
1997). Throughout the early development of acupuncture
it is important to note that traditional Chinese medicine
approaches and treatment philosophies were based upon
subjective perceptions and in the absence of medical
dissection or surgical exploration (Basser 1999; Unschuld
1985; White and Ernst 2004).
The practice of acupuncture was adopted by Japan
and Korea in the sixth century and by Vietnam between
the eighth and tenth centuries (Baldry 2005). France led
the way in Europe, adopting the practice of acupuncture
after Jesuit missionaries returned with reports of its
practice in the sixteenth century. In 1683, the first medical
treatise to appear in the West on ‘acupuncture’ (a term
coined by its author from the Latin acus = needle and
pungere = to prick) was written by the physician Willem
Ten Rhijne (Bivins 2000; Baldry 2005). Throughout
the eighteenth century, in both Europe and America,
doctors practised acupuncture, formulating a Western
rationale based on the scientific discoveries of their day
(Kaptchuk 2000).
Ironically, this was at a time when acupuncture use
was falling out of favour in China (Baldry 2005). By the
mid-nineteenth century acupuncture had become unfash-
ionable and politically incorrect in the west, and in China
its use was restricted to rural areas following a decree by
the Daoguang Emperor citing it as an impediment to
medical advancement (Ernst and White 1999). This decree
effectively meant that acupuncture was no longer officially
recognised by The Imperial Medical Institute and was,
along with other forms of traditional Chinese medicine,
banned in 1929 in favour of modern scientific medicine
(Ma 1992).
403
 Tidy’s physiotherapy
Acupuncture in the   the surgical benefits of Chinese acupuncture first hand
twentieth century
In 1949 with Chairman Mao Tse-Tung as head of the com-
munist revolution and the establishment of The People’s
Republic of China, acupuncture, along with other forms
of traditional Chinese medicine experienced a revival. This
resurgence in traditional Chinese medicine was largely for
political reasons and linked to the Cultural Revolution in
China (Unschuld 1985). In fact, it was at this time that
the existing divergent forms of therapeutic intervention in
China were consolidated into what we now refer to as
traditional Chinese medicine (Birch and Kaptchuk 1999).
Alongside this, research into acupuncture was promoted
in China which later led to Han’s work into the effects
acupuncture may have on neurotransmitter release (Han
and Terenius 1982). Owing to China’s political isolation
this renewed enthusiasm for traditional Chinese medicine
went unnoticed by the West until the early 1970s.
In preparation for Richard Nixon’s 1972 visit, Henry
Kissinger visited China in 1971. Among his press entou-
rage was a man who was surgically treated for acute
appendicitis while in China and received postoperative
acupuncture for abdominal pains (Reston 1971). His
report of this care in the New York Times was the
catalyst for a rush of interest by US physicians in seeing
Figure 18.1  Model of traditional acupuncture points.
404
(Diamond 1971). Perhaps the most enduring and con­
troversial of these first-hand experiences was when Dr
Isadore Rosenfeld observed open heart surgery in a young
female patient ostensibly using acupuncture points in her
ear (auricular acupuncture) with electrical stimulation
(electro-acupuncture) in place of standard anaesthetics. It
now seems clear that what Dr Rosenfeld observed was, at
best, an exaggeration of the analgesic affects of auricular
electro-acupuncture and, at worst, and more likely, an
elaborate hoax with much of the analgesic effect being
attributable to low doses of midazolam, droperidol and
fentanyl. Nonetheless, this and the experiences of other
visiting physicians, galvanised interest in acupuncture
analgesia among the medical community at the time.
Unfortunately, reports of these experiences were presented
more as sensationalist journalistic pieces than objective
academic works and much of the hype regarding the
potential benefits of acupuncture this created was not
well founded. Indeed, a recent systematic review by
Lee and Ernst (2005) concluded that the evidence for
acupuncture analgesia in surgery was inconclusive.
ACUPUNCTURE FROM A TRADITIONAL
CHINESE MEDICINE PERSPECTIVE
Acupuncture is an intervention involving the insertion and
manipulation of fine needles into the body to achieve a
therapeutic effect. From a traditional Chinese medicine
perspective the anatomical sites at which these needles are
inserted are specified and these points are located along
channels (mai in Chinese) that have come to be known as
meridians in the West (in part owing to their similarity
to geographical meridian lines). It is worth noting that
ancient texts demonstrate that these meridians were devel-
oped from clinical experience with moxibustion and not
acupuncture (Harper 1998). There are 12 principle merid-
ians with both superficial and deep representations, and a
number of so-called extraordinary meridians. Again, from
a traditional Chinese medicine perspective, these meridi-
ans are believed to have specific effects on the physiology
of body organ systems and are named accordingly, for
example Lung (LU), Heart (HT), Pericardium (PC),
Stomach (ST), Large Intestine (LI), Small Intestine (SI)
and Bladder (BL) meridians (Figures 18.1 and 18.2).
The insertion of acupuncture needles and their stimula-
tion either manually or via electrical stimulation is
believed to effect the flow of qi, pronounced ‘chi’, and
commonly translated as vital energy, life force or spirit,
while a literal translation of the Chinese character for
qi is ‘vapors rising from food’ (Basser 1999). It is believed
in traditional Chinese medicine that by effecting qi
flow along the meridians a person’s overall health and
well-being can be beneficially influenced. In order to

Figure 18.2  Typical acupuncture needle.
effectively produce this therapeutic effect it is commonly
believed that needling stimulation is required to produce
a specific sensation know in Chinese as de qi and described
as a deep heavy aching sensation which may propagate
along the needled meridian.
Diagnosis in traditional Chinese medicine conceptually
views the health status of an individual as a microcosm of
nature and thus could be viewed as a human meteorologi-
cal report (Kaptchuk 2002). Linked to this are the concepts
of five fundamental universal elements and that of balanc-
ing a person’s yin and yang with those of nature, terms
originally denoting the shaded and sunny aspect of a hill
respectively. These terms of yin and yang are also used to
classify acupuncture meridians, the former being on the
inner aspect of a limb and the latter on the outer aspect.
In traditional Chinese medicine, the body is viewed as
being comprised of functional systems or zang-fu in
Chinese. Though not directly associated, each system is
named according to an organ. The zang systems are linked
with the solid, yin organs, for instance the kidneys, while
the fu systems are linked with the hollow yang organs, for
instance the stomach.
The individual acupuncture points are named and num-
bered according to the meridian along which they are
located, for example LI4, ST36. Points are located on an
individual’s body in relation to tendons, muscles and
bony points, and a system of proportional measurements
using the ‘cun’ as its base measurement which is the width
of that individual’s interphalangeal joint of the thumb
(Cheng 1987). Palpation is also viewed as being of great
importance in locating points to needle. Historically, and
in keeping with the traditional Chinese medicine view of
health being related to a numerical and holistic paradigm,
365 points were described to reflect the days of the year
without any further objective basis (Lun 1975). In addi-
tion to the overall effects which needling these points can
have on an individual’s health and organ function, in
traditional Chinese medicine specific acupuncture points
Acupuncture in physiotherapy Chapter 18
are anecdotally believed to have specific effects on certain
conditions, for example PC6 for nausea and vomiting,
GB37 for conditions related to vision and BL60 for lower
back pain (Maciocia 2005). These points are commonly
referred to as ‘empirical’ points.
In addition to these classical meridian points, needle
insertion can be directed locally to the symptomatic area
or into points of maximal tenderness referred to as ah-shi
(translated as ‘oh yes’/‘that’s it’) points. Interestingly, the
Chinese character used to denote an acupuncture point
can also mean ‘hole’ suggesting that acupuncture points
may be viewed as points of access to structures deeper in
the body (Langevin and Yandow 2002).
WESTERN MEDICAL ACUPUNCTURE
In 2000, the British Medical Association recommended
the integration of acupuncture into practice (Silvert
2000). On the face of it, Western medical acupuncture
may appear very similar to traditional Chinese medicine
acupuncture. Needles are inserted often both local to the
symptomatic region of the body and more distally along
the arm or leg, often with points in the hand or foot.
Once the needles are in place they are typically manipu-
lated by hand or by electrical stimulation over the course
of a treatment lasting anywhere from 5–30 minutes. The
points are typically named using traditional Chinese
medicine terminology and often empirical points are
added to the points used. The key differences between
Western and traditional Chinese medicine acupuncture
is in the patient assessment, expectation and in the
intention behind the treatment itself. While a traditional
Chinese medicine approach would typically assess a
patient’s ‘qi balance and flow’ by taking a history and
using observation of the tongue, eyes and specific palpa-
tion of the pulse, a Western approach would seek to make
a clinical diagnosis based on pathology using history and
clinical assessment findings. In terms of the treatment
itself, a traditional Chinese medicine practitioner would
seek to alter qi movement and flow by needling, whereas
a Western practitioner would attempt to stimulate specific
neurochemical and both connective and contractile tissue
responses by needling. In addition, a traditional Chinese
medicine practitioner would chose points according to
meridians with a consideration of the effects this may
have on organ system physiology. Although Western acu-
puncture may still use classic traditional Chinese medi-
cine nomenclature to specify the points used often no
consideration is given to the potential effects on organ
systems, for instance in the case of using points along
the bladder meridian to treat lower back pain. Instead,
the local, segmental, extra-segmental and central neuro-
logical effects are what concern a Western acupuncture
practitioner.
405
 Tidy’s physiotherapy
Prevalence of acupuncture use
Acupuncture use by general practitioners (GPs) in the UK
is increasing and it is now likely to be the most prevalent
of all complementary therapies. Thomas et al. (2001)
reported that in 1998 approximately 7% of English
adults had received acupuncture treatment at some point.
Within National Health Service (NHS) chronic pain
clinics, acupuncture is estimated to be offered in 84%
of cases (Woollam and Jackson 1998). According to the
Acupuncture Association of Chartered Physiotherapists
(AACP) there are approximately 5000 AACP-registered
physiotherapists now working in the NHS and in private
practice in the UK.
Safety of acupuncture
As with any physiologically active and invasive therapeutic
intervention, considerations of not only the effectiveness
but also of the safety of acupuncture are necessary.
The mere fact that acupuncture has been practised for
centuries does not provide sufficient evidence of its
safety. Historically, autoclave procedures were employed
for sterilising needles and it was not until reports of acu-
puncture-related cross infection, such as hepatitis B (Kent
et al. 1988) coupled in no small way with the outbreak of
AIDS in the 1980s, that single-use needles were advocated.
It is clear that reports of adverse events and more serious
complications attributed to acupuncture during the 1970s
and 1980s highlight the improvements in acupuncture
safety that have been made in the past three decades.
Further reports of acupuncture-associated hepatitis B
transmission were, however, reported in the 1990s (Rosted
1997; White 1999). The latter of these reports not only
recommended the use of single-use, disposable needles,
but also the vaccination of all acupuncture practitioners
against hepatitis B. During the 1990s it was proposed that
a theoretical risk of transmitting variant Creutzfeldt-Jacob
Disease existed even with autoclaved needles, further sup-
porting the use of sterile single-use needles.
In 1999, Peuker et al. reported on the importance of
acupuncture practitioners having a sound knowledge of
surface and deep anatomy, at least to the depth of needling
which can vary from a few millimetres to several centime-
tres. In this report, potential sites of traumatic lesions
by needling are divided into those affecting the thoracic
viscera, abdominal viscera, peripheral and central nervous
system (CNS) structures. In the thoracic region attention
is drawn to the presence of a sternal foramen in a small,
but not insignificant, proportion of the population level
with the fourth intercostal space. Needling perpendicu-
larly through this foramen if present when using the acu-
puncture point referred to as conception vessel 17 (CV17)
carries the risk of causing a cardiac tamponade.
The other potential complication in the thoracic region
is injury to the lungs or pleura through needling. Needling
in the parasternal region or along the midclavicular line
406
to a depth of 10–20 mm has been shown to be sufficient
to reach the lungs in cadaveric study. Numerous cases
of pneumothorax induced by acupuncture have been
reported (White 2004). Points which have resulted in
injury to these structures include Stomach 11 and
12 (ST11, ST12). Caution should be exercised when nee-
dling Stomach 13 (ST13), Lung 2 (LU2) and Kidney 27
(KID27). Kidney (KID22–KID27), Stomach (ST12–ST18)
and Bladder (BL41–BL54) points should all be needled
bearing in mind the depth of the lung at these sites. As
far as the abdominal viscera are concerned, few reports
of complications have been published apart from rare
lesions of the intestine and bladder, plus a report of a
foreign body in a kidney identified as an acupuncture
needle.
Peripheral nerve injuries may occur in cases of patients
with atypical median nerve courses at the wrist. Points to
note in this instance are Pericardium 6 and 7 (PC6, PC7)
and Lung 8 (LU8). In the lower limb a number of points
are located over peripheral nerve pathways. For instance,
Bladder 39 (BL39) and potentially Gall Bladder 34 (GB34),
the common peroneal nerve and Bladder 40 (BL40), and
the tibial nerve and popliteal vessels.
Four reports of blood vessel injury are briefly detailed
by Peuker et al. (1999). These involved a partially throm-
bosed pseudoaneurysm adjacent to the costocervical artery
(Fujiwara et al. 1994), a false aneurysm of the popliteal
artery following deep needling of Bladder 40 (BL40) (Lord
and Schwartz 1996), a deep vein thrombophlebitis in the
upper calf (Blanchard 1991) and anterior compartment
syndrome in the upper calf in a patient on anticoagulant
therapy (Smith et al. 1986).
A series of articles by Peuker and Cummings (2003a,
2003b, 2003c) expanded upon this work of examining
anatomy as it pertains to acupuncture. These three articles
divided the body into three sections: the head and neck,
the chest, back and abdomen, and the upper and lower
limbs, and detailed the pertinent neuromusculoskeletal
anatomy to guide acupuncturists in targeting the intended
target and avoiding neurovascular targets.
A review by Ernst and Sherman (2003) concluded that
in almost all cases poor practice and lack of adherence to
recommended hygiene procedures was responsible for
serious adverse reactions to acupuncture. This fact obvi-
ously supports the continued regulation of acupuncture
practitioners by organisations such as the British Medical
Acupuncture Society (BMAS) and the AACP in the UK.
ACUPUNCTURE RESEARCH IN  
THE TWENTIETH CENTURY
Throughout the 1970s much of the medical and scientific
community attributed the benefits of acupuncture to the
placebo effect. However, this belief failed to account for
the benefits of acupuncture in young children and in

animals. In order to satisfy standards of Western scientific
rigor and understandable scepticism regarding acupunc-
ture and its effects, clinical research was required. Western
evidence-based medical research into acupuncture has
since largely dismissed traditional Chinese medicine con-
cepts of qi and meridians. In their place neurochemical
and anatomical models have been proposed based on the
best evidence from research studies. At the extreme this
Western scientific approach is typified by Felix Man’s asser-
tion in the 1970s that ‘Acupuncture points and meridians
in the traditional sense, do not exist’ (Mann 2004).
Principally, this research investigated the analgesic
effects of acupuncture. Initially, the best theory to explain
acupuncture analgesia was the gate control theory of pain
proposed by Melzack and Wall in the 1960s (Melzack and
Wall 1965). The fundamental basis of this model was that
a counter stimulus could effectively supersede the noxious
stimulus at the spinal cord level thus suppressing the noci-
ceptive pathway.
During the late 1970s extensive research was performed
by Bruce Pomeranz, alone and with others. Pomeranz
used research evidence to outline a sequence of neuro-
chemical events following the insertion of an acupuncture
needle. At spinal cord level the acupuncture stimulus was
believed to stimulate the release of dynorphin and
encephalin leading to the attenuation of noxious trans-
mission. At mid-brain level a further release of encephalin
affected a descending inhibitory pathway back to the
spinal cord. Finally, Pomeranz proposed that at the level
of the hypothalamus the stimulation of release of beta-
endorphin into the mid-brain by the arcuate nucleus
and pituitary re-enforced this descending inhibition
(Pomeranz and Chui 1976; Pomeranz et al. 1977;
Pomeranz 1978). Subsequent research focussed on the
potential effects acupuncture may have on the release of
opioids, such as endorphin. One of the most significant
and seminal of these pieces of research was carried out in
Beijing and looked into the neurochemistry of acupunc-
ture analgesia (Han and Terenius 1982). This study found
that acupuncture could affect the release of neurotrans­
mitters, especially opioid peptides, which could explain its
analgesic effects.
Throughout the 1970s and 1980s frequent but ulti-
mately inconclusive attempts were also made to find ana-
tomical correlates for acupuncture points. These studies
pointed to the endings of a variety of sensory nerves
(Ciczek et al. 1985), areas of dense neuro-vascularity
(Bossy 1984) and motor end-plates (Liu et al. 1975; Gunn
et al. 1976; Dung 1984) as potential anatomical target
sites for needling. Another line of research looked at the
physiology of acupuncture points. On many occasions
skin conductance has been evidenced to be higher at acu-
puncture points when compared with adjacent skin
(Reichmanis et al. 1976; Comunetti et al. 1995). Unfortu-
nately, inadequate statistical testing, control and subject
numbers have adversely affected the quality of these
studies.
Acupuncture in physiotherapy Chapter 18
Brain imaging acupuncture research
With the advent of positron emission tomography (PET)
scanning and, in particular, functional magnetic resonance
imagery (fMRI) in the 1990s, there was a new method of
investigating the cortical effects of needling in acupunc-
ture. For instance, it was possible to study the effects of
needling on activity in areas of the brain believed to be
associated with the processing and perception of pain.
While such research took many forms and investigated
acupuncture from a variety of different perspectives,
perhaps the most talked about study was published in
1998 and sought to correlate brain activity with an empiri-
cal point associated with visual disorders (Cho et al.
1998). This study focussed on an acupuncture point
located on the lateral aspect of the foot referred to as
Bladder 67 (BL67) which, according to traditional Chinese
medicine theory, is an empirical point used in the treat-
ment of eye disorders (Kaptchuk 2000; Stux et al. 2003).
The authors observed fMRI activity in the brain stimulated
by needling BL67 and fMRI activity stimulated by visual
light stimulation. A correlation was found between the
specific areas of cortical activation leading the authors to
claim that this supported traditional Chinese medicine
theory regarding this empirical point. However, a retrac-
tion was published in 2006 by the authors of the original
article aside from three: J.P. Jones, J.B. Park and H.J.
Park. The other five authors stated that they ‘no longer
agree with the results’ of the original article and conclude
from research carried out in the intervening years that
there is no research evidence to support point specificity
in acupuncture.
By the turn of the century, research had revealed
evidence that acupuncture had a role in the regulation of
a variety of physiological functions, protection against
infection and as an analgesic (WHO 1999). More specific
study revealed that needle manipulation at the point
known as Large Intestine 4, or LI4, could modulate activity
as seen on fMRI in the limbic system of the brain and
in subcortical regions (Hui et al. 2000). This finding
could go some way towards explaining some of the anec-
dotally reported multisystem clinical effects of acupunc-
ture treatment.
The World Health Organization’s (WHO) review of
acupuncture evidence in 1999, which limited its scope
to randomised controlled and controlled clinical trials
with adequate subject numbers, advocated the use of
acupuncture for pain relief, especially in chronic cases.
This is because for chronic pain states, acupuncture has
been shown to be equally effective as morphine but
without the potential side effects. Of note is the similar-
ity between conditions where acupuncture is advocated
and those where an element of central sensitisation is
suggested, such as osteoarthritis, some forms of head-
aches, fibromyalgia and musculoskeletal disorders with
generalised pain and hypersensitivity, such as chronic
lower back pain.
407
 Tidy’s physiotherapy
Acupuncture use is supported in the WHO report for the
management of headaches and a variety of musculoskel-
etal conditions such as neck pain or cervical spondylitis
(David et al. 1998), fibromyalgia (Deluze et al. 1992),
common extensor tendinopathy of the elbow (Haker and
Lundeberg 1990; Molsberger and Hille 1994), knee oste-
oarthritis (Berman et al. 1999) and chronic lower back
pain (Lehmann et al. 1986).
In the case of rheumatoid arthritis the WHO report cites
evidence supporting the benefits of acupuncture treat-
ment to address the pain, inflammation and immune
system components of this auto-immune condition
(WHO 1999). Furthermore, and in summary, the report
presents some convincing evidence supporting the use of
acupuncture in the treatment of traumatic and postopera-
tive pain (Jiao 1991), as an adjunct in stroke rehabilita-
tion (Johansson et al. 1993) in reducing exercise-induced
asthma (Fung et al. 1986), as an anti-emetic (Vickers,
1996), and in some gynaecological and obstetric condi-
tions (Helms 1987; Chen 1997).
Of note is the fact that this WHO report included reports
published in Russian, Chinese, Japanese, German, Danish
and Indonesian, and loosely defined acupuncture as a
treatment to include standard needling, electro- and auric-
ular acupuncture, moxibustion and, in some research,
included the use of cupping. It is worth pointing out that
research published in Chinese was second only to that
published in English and this fact does deserve considera-
tion when interpreting the findings owing to potential
culturally driven variations in treatment expectation.
Acupuncture research since the turn
of the twenty-first century
Perhaps the most significant development in acupuncture
research since the turn of the century was a series of obser-
vational and controlled studies, now commonly referred
to as the GERAC trials. These trials were instigated by
insurance companies across Germany in response to the
increasing expense of claims where acupuncture was part
of the treatment. These trials led to the publication
of studies involving much larger subject numbers and
investigated the use of acupuncture in the treatment
of migraines (Linde et al. 2005), tension type headache
(Melchart et al. 2005), chronic neck pain (Willich et al.
2006), chronic low back pain (Brinkhaus et al. 2006),
and osteoarthritis of the hip and knee (Witt et al. 2006).
The fundamental outcome of these trials was that
German insurance companies were sufficiently convinced
by the evidence for acupuncture in the treatment of knee
osteoarthritis and chronic lower back pain that they would
fund it as part of treatment. In the case of the other condi-
tions investigated, the insurance companies were not con-
vinced that acupuncture provided sufficient benefits over
and above usual care or sham acupuncture procedures.
408
The National Institute for Health and Clinical Excellence
2009 recommendations for treating lower back pain also
supported the use of acupuncture treatment.
Interestingly, a Cochrane Review by Linde et al. (2009)
of acupuncture for tension type headaches stated that ‘acu-
puncture could be a valuable non-pharmacological tool in
patients with frequent episodic or chronic tension-type
headaches’ in light of research published since 2006, such
as Endres et al. (2007) and Jena et al. (2008). The Cochrane
Review into acupuncture for prevention of migraines by
Linde et al. (2009) concluded that on the basis of recent
research that ‘Acupuncture should be considered a treat-
ment option for patients willing to undergo this treat-
ment.’ Benefits of acupuncture were seen to be as good
as pharmacological treatment with fewer side effects;
however, no statistically significant difference was noted
between the effects of ‘true’ versus ‘sham’ acupuncture
procedures. This furthers the debate as to whether depth
of needling and location of needling, for instance, are of
importance over and above the benefits of intent and
expectation.
A 2010 review into acupuncture for peripheral osteoar-
thritis (including osteoarthritis of the hip, knee and
hands) concluded that while the benefits of acupuncture
versus sham procedures were statistically significant they
were not, however, felt to be clinically significant. This
finding may well be a result, somewhat ironically perhaps,
of larger subject numbers involved in research studies.
When compared with waiting list care the benefits of
acupuncture were found to be both statistically and clini-
cally significant. However, in all cases it was felt that the
benefits of acupuncture could reasonably be attributed to
intention and/or expectation – in short a placebo effect
(Manheimer et al. 2010).
As far as more recent evidence for acupuncture treat-
ment of neck pain is concerned, a 2007 review by Trinh
et al. suggests that moderate evidence exists to support
the use of acupuncture use for treating chronic neck
pain (Trinh et al. 2007). Among other areas of recent
research interest are upper limb, lower back and pelvic
pain in pregnancy, chronic knee pain, myofascial pain and
fibromyalgia.
Unfortunately, all too often acupuncture research has
lacked sufficient methodological rigor, adequate subject
blinding or sufficient subject numbers to adequately in­­
vestigate this multifaceted intervention. Much of the
research into acupuncture has been dogged by a lack of an
adequate placebo with which to compare ‘true acupunc-
ture’. No clear agreement exists as to what is an adequate
dose of acupuncture. Trials have used ‘minimal needling’,
non-acupuncture point needling or sham acupuncture
needling, and ‘placebo needling’ using retractable non-
penetrating needles to attempt to remedy this situation
(Streitberger and Kleinhenz 1998; White et al. 2003).
However, the near universal result is that these supposed
control or placebo conditions have, at least in terms

of statistical evaluation, essentially matched the ‘true
acupuncture’ in terms of its effects. Therefore, in acupunc-
ture research, as in medical trials, the placebo condition
remains a clinically active intervention. This has led scep-
tics to brand acupuncture as being no better than a placebo
and advocates to claim that the control conditions used
were therapeutically active interventions. A key considera-
tion that can be overlooked here is the fact that a placebo
effect, which can be dismissed, is, nonetheless, a real treat-
ment effect. As in pain science, assuming we have con-
signed Cartesian dualism to history, this means that the
so-called control conditions used in research are clinically
active and produce effects on the brain (Campbell 2009).
What now appears clear is that even superficial pressure
via sham needling as part of a therapeutic intervention can
have significant effects on the brain’s limbic system under-
lying the importance of a patient’s expectation and beliefs
in any treatment response (Pariente et al. 2005). This
concept and, more specifically, the role that C tactile fibres
may play in the outcome of all manual therapy is worth
bearing in mind in both research and clinical settings
(Campbell 2006a). It is accepted that portions of the
limbic system of the brain form part of the pain neuroma-
trix but also are commonly referred to as the emotion and
reward centre. Following on from this there appears to be
a suggestion that superficial needling may be more effec-
tive in conditions such as headaches and migraines with
a large affective component versus conditions with largely
sensory components, such as knee arthritis (Lund and
Lundberg 2006).
Despite the clear difficulties associated with construct-
ing sound clinical trials to assess the benefits of acu-
puncture, some review articles have recently supported
its use in three disparate conditions. A meta-analysis
by Manheimer et  al. (2005) supported the use of acu-
puncture in treating lower back pain; Ezzo et  al. (2005)
supported acupuncture use in the treatment of
chemotherapy-induced nausea and vomiting; and White
et  al. (2007) found evidence that acupuncture was more
effective than placebo in treating chronic knee pain.
The current Western scientific
understanding of acupuncture
So what do we now understand is happening from a neu-
rochemical point of view when acupuncture is used as a
treatment? Biomedical acupuncture theory recognises that
acupuncture modulates central, peripheral and autonomic
nervous system activity (Wu et al. 1999). Chemical media-
tors in the CNS have been implicated in the mechanism
of acupuncture since a study by the Research Group of
Acupuncture Anaesthesia in Peking Medical College
(1974) took cerebrospinal fluid of rabbits treated with
acupuncture and effected increased pain thresholds in
rabbits by injecting this into their cerebral ventricles. Early
Acupuncture in physiotherapy Chapter 18
research into acupuncture mechanisms revealed that stim-
ulation of local nerves was at least partly responsible for
its effects. Han and Terenius (1982) noted that acupunc-
ture analgesia was blocked by procaine infiltration of
points and Wang et al. (1985) demonstrated that acu-
puncture needling stimulated nerve action potentials. It
has also been shown that it is not possible to elicit acu-
puncture analgesia in paraplegic or hemiplegic patients
which underlines the importance of intact afferent path-
ways (Han and Terenius 1982).
It has been shown more recently that stimulation of
small diameter type II and III myelinated sensory nerve
fibres in muscles may have a role in the initiation of acu-
puncture analgesia. Interestingly, the needling sensation
known as ‘de qi’ has been shown to occur in tandem with
action potentials typical of those propagated by and along
these type II and III fibres.
As far as the potential anti-inflammatory effects of
acupuncture are concerned, beta-endorphin and adreno-
corticotropic hormone release into the circulation may
produce systemic effects such as changes in T-lymphocyte
levels plus natural killer cells, and an increase in the
production of anti-inflammatory corticosteroids by the
adrenal glands respectively (Takeshige et al. 1992; Sato
et al. 1997; Lundeberg 1999).
What consistently appears in the scientific literature are
studies linking the effects of acupuncture to modulation
of activity in the limbic system of the brain. This may
mean that as far as anti-nociceptive effects, acupuncture
alters pain perception using a pathway common to placebo
treatments, hypnosis and, potentially, manipulations
(Campbell 2006b). The limbic system plays a leading role
in maintaining homeostasis in the body (Craig 2002,
2003). This fact, coupled with the fact that acupuncture
modulates activity within the limbic system, may explain
acupuncture’s ability to stimulate or inhibit metabolic
processes as required for a return to a healthy state.
Recent study has identified that the local analgesic
and potentially the anti-inflammatory effects of acupunc-
ture are mediated by adenosine A1 receptors (Goldman
et al. 2010).
Somatic sensory stimulation activates impulse
relays in the CNS, which then alter processing
and output.
Robinson (2007)
It should be noted that fear and anxiety states consistent
with sympathetic arousal may reduce acupuncture para-
sympathetic actions.
Western correlates of traditional
Chinese medicine paradigms
The search for anatomical and physiological correlates of
acupuncture points and meridians has produced many
409
 Tidy’s physiotherapy

plausible theories but has largely been inconclusive. One connective tissue winding is necessary to stimulate the
of the more convincing theories was that an overlap afferent fibres necessary for effecting central descending
existed between acupuncture points and myofascial trigger inhibition. This, however, may be at odds with the consist-
points. However, despite the specific criteria for what con- ent finding that so-called ‘sham’ or placebo acupuncture
stitutes a trigger point, some difference of opinion remains has effects not statistically significantly different from
as to whether trigger points are muscular or fascial entities. ‘true’ acupuncture.
Kawakita and Okada (2006) describe both acupuncture
points and trigger points as ‘sensitised polymodal recep-
tors’ which may be treated with a variety of interventions.
A number of authors have proposed a potential correla-
CONDITIONS THAT MAY BE TREATED
tion between connective tissue planes and acupuncture – FROM THE AACP SITE
meridians (Larson 1990; Oschman 1996; Ho and Knight
1998; Langevin and Yandow 2002; Dorsher 2009; Fung A large range of conditions can be treated successfully by
2009). For instance, Fung (2009) explored the connective acupuncture within physiotherapy. Some are shown in
tissue interstitial fluid system, mechanotransduction and Box 18.1.
mast cell degranulation, while Ho and Knight (1998)
investigated the liquid crystalline collagen fibres of con-
nective tissue in relation to acupuncture meridians. This Clinical implications
line of work may fit well with acupuncture points as Unfortunately the very nature of much of the research
portals to deeper tissues are often referred to as fascia and evidence available means that individual effects and vari-
connective membranes in historical texts (Matsumoto and ations are watered down and lost in the statistical analysis.
Birch 1988). It is this heterogeneity that clinicians must grapple with in
The work of Helen Langevin has provided further exper- their daily practice and for which research all too often
imental evidence to support the potential relationships offers limited guidance. This is likely to be the reason why
between connective tissue and acupuncture mechanisms. there is a lack of agreement among acupuncture practi-
An article by Langevin and Yandow (2002) demonstrated tioners in their treatments.
an 80% overlap between acupuncture point locations in For instance, what constitutes an adequate dose of acu-
the upper limb and inter or intramuscular septa. This has puncture in practice? Consideration needs to be given to
led to the proposal that needling at acupuncture points the patient’s present state from a psychological, neurologi-
targets interstitial loose connective tissue and not muscles, cal, immunological and endocrine perspective (White
and that this tissue forms a continuous dynamic signalling et al. 2008). This is similar to the considerations that may
network responsible for the effects of acupuncture. This be given before prescribing rehabilitative exercises to a
theory echoes the recent reconceptualisation of functional patient. It is also important to acknowledge the priming
anatomy and work into myofascial meridians and tenseg- effect of patient expectation and belief on the reward
rity model in the field of manual therapies by Thomas centres of the brain. If we consider the importance of this
Myers (2009). then what clinicians say to patients as a preamble to the
Scientific study of the biomechanical response to nee-
dling has demonstrated that the measured force required
to extract needles (indicative of needle grasp which can
accompany eliciting a ‘de qi’ response) was greater at acu- Box 18.1 
puncture points than non-acupuncture points (Langevin • Acute injuries • Asthma
et al. 2001). In addition, Langevin et al. (2001) and
• Sports injuries • Bronchitis
Langevin et al. (2002) demonstrated evidence that the
• Whiplash • Strokes
needle grasp was a response not by muscular tissue but
involving connective tissues, which may modulate mech- • Back pain • Multiple sclerosis
anosensitive gene expression. • Neck pain • Migraine
What of the manipulation of the needle once it is in situ? • Headaches • Irritable bowel
The work of Langevin et al. (2004, 2006, 2007) investi- • Stress-related illnesses • Skin conditions
gated connective tissue responses to needling. Findings • Chronic injuries • Eczema
included a winding specific to loose areolar tissue around • Osteoarthritis • Allergies
the needle and remodelling of fibroblasts in the connec- • Rheumatoid arthritis • Breathing difficulties
tive tissue in response to needle rotation and linear • Joint pain • Hay fever
manipulation. The next stage in this research was to • Women’s health • Chronic fatigue
explore the therapeutic value of stimulating deep con­ syndrome (ME)
• Hormone imbalances
nective tissues in this way, outwith the effects on sensory • Bladder and bowel
nerves, blood vessels and immune cells. There is a dysfunctions
suggestion from research by Yu et al. (2009) that deep

410
 Acupuncture in physiotherapy Chapter 18

use of acupuncture as a treatment and their clinical inten-

tions may influence treatment outcomes (Pariente et al.
2005). This may be of most importance when the patient’s
condition has a dominance of affective versus sensory
components.
Variables that need consideration from a practical
treatment perspective include the number of needles
used, the location and depth of needling and the nature
of needle stimulation or manipulation. In addition, the
duration and frequency of treatment needs to be indi­
vidually tailored to each patient. A degree of active, but
safe, experimentation is necessary in order to investigate
each patient’s dose–response relationship, again in much
the same way one would assess a patient’s exercise or
aerobic capacity. From here, as with all clinical practice,
reasoning and outcome assessment needs to be regular
and patient-centred.
What can assist the clinician in treatment selection is to
consider the treatment goals based on their clinical diag-
nosis. For instance, are you looking for effects peripherally,
at spinal cord level or centrally? Consideration needs to
be given to the type of pain, whether it is nociceptive,
neurogenic or centrally evoked, as well as the stage of
tissue repair. For instance, in acute pain a segmental effect
may be required but may best be elicited by needling
points within a common dermatome, myotome or scle-
rotome if trigger point needling is likely to be irritable and
poorly tolerated.
Peripheral effects you may wish to produce include an Figure 18.3  Acupuncture needle at the Large Intestine 4
increase in substance P, histamine and calcitonin gene (LI4) point in situ.
related peptide (CGRP) leading to local vasodilation and
modulation of the local immune response. This can be
provoked by a treatment lasting from 10–20 minutes. For effect (MacPherson et al. 2001; Kong et al. 2007)? De qi
spinal effects the use of the relevant bladder points or is accepted to be a feeling of spreading heavy soreness
huato points is suggested in order to attenuate the nocic- and distension during needling manipulation (Wu et al.
eptive input at dorsal horn level. Finally, for supraspinal 1999). Studies have revealed that producing a de qi
effects such as stimulation of the arcuate nucleus and response produces a pattern of reduced activity in the
hypothalamus to envoke descending inhibition, periph- limbic and cerebellar brain regions that is distinct from
eral points such as LI4 and LIV3 are suggested owing to that produced by either minimal needling or painful nee-
their large representation on the somatosensory cortex. In dling (Hui et al. 2005; Asghar et al. 2009). From a clinical
this case the treatment time may be extended from 20–40 standpoint, then, the consistency of needling sensation
minutes and involve more aggressive needle manipula- may well be a determinant of successful treatment with
tion. This may additionally produce changes in the auto- acupuncture. This may be especially the case if the condi-
nomic system output and endocrine systems (Bradnum tion being treated has a dominant affective component
2007). It is worth considering here that research by Fang and treatment is targeting the pain neuromatrix in the
et al. (2004) did not find evidence that the nature of brain. Furthermore, the treatment of painful conditions
needle manipulation significantly affected the neuronal such as lower back pain with a segmental approach may
response. differ from that of non-painful conditions, such as nausea
What of the needling response commonly known as with PC6 where greater point specificity may be justified
de qi which has been synonymous with treatment (Lewith et al. 2005) (Figure 18.3).

ACKNOWLEDGEMENTS

The author would like to acknowledge the assistance he received from Dr Val Hopwood (course director for the MSc in
Acupuncture at Coventry University) at the first draft stage of the chapter.

411
 Tidy’s physiotherapy
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 Chapter
Electrotherapy
Tim Watson
INTRODUCTION
Electrotherapy has been a component of physiotherapy
practice since the early days of the profession. Modern
electrotherapy use deserves to be evidence-based and the
modalities used judiciously. When used appropriately,
electrotherapy modalities have a demonstrable capacity to
achieve significant benefit. Used unwisely, they will either
do no good at all or, worse still, aggravate the clinical
condition. In addition to the delivery skills of each modal-
ity, there is a critical skill in making the appropriate clini-
cal decision as to which modality to use and when.
It is commonly argued that electrotherapy has little, or
no, value in modern physiotherapy practice, and that it
lacks an evidence base and so should be ‘left out’ of the
treatment options. It is not uncommon to find whole
clinics or departments that have decided not to deliver
electrotherapy any longer on this premise. As you will see
from the information in this chapter (which is not a full
review of the evidence – just a brief summary of it), there
is a substantial evidence base behind these modalities and
if we were to deliver ‘evidence-based therapy’, then elec-
trotherapy would be included – not for everything – but
certainly for a significant range of musculoskeletal and
associated presentations.
With regard the mechanisms by which each modality
achieves its effects, it is important to realise that it is not
the modality per se which brings about the therapeutic
benefit. The applied energy stimulates or induces a physi-
ological response. It is the physiological response which,
in turn, brings about the therapeutic effects. The key to the
application of electrotherapy is the relationship between
these concepts. The therapist working with an electrother-
apy modality is using, or manipulating, the physiological
changes in order to achieve the desired effect. It may seem
to be a pedantic argument, but it is a critical point. The
outcome of the therapy is achieved through physiological
19 
manipulation and this concept applies to the application
of all electrotherapy modalities.
A further very important concept is that the electro-
therapy intervention is only a component of the overall
treatment package. It is rarely appropriate for a patient to
receive electrotherapy in isolation. It is most effectively
combined with a range of manual therapies, exercise,
advice and education. The elements of the treatment
package need to be complementary. Careful construction
of treatment programmes will enable the most effective
outcome. It may be that the electrotherapy components
are only utilised for the first few sessions or, indeed, only
for the sessions later in a series. Electrotherapy is not an
essential component for all patients and should only be
used when and where appropriate.
Electrotherapy versus  
electrophysical agents
There is a general shift to move away from the term ‘elec-
trotherapy’ toward a more encompassing term of ‘electro-
physical agents’ (EPAs). This is largely to be welcomed
in that electrotherapy, in the strictest sense of the term,
would only apply to those modalities which involved the
delivery of electrical, and possibly also electromagnetic,
energies (e.g. transcutaneous electrical nerve stimulation
(TENS), interferential therapy (IFT)). Ultrasound, light,
vibration and various heat therapies, for example, would
not fit this more narrow definition. As a term, EPA is cer-
tainly more inclusive and thus a more accurate reflection
of the wide range of modalities employed in physiother-
apy (Watson 2010). A general shift away from the term
electrotherapy and towards a more common use of EPAs
is anticipated over the next few years. The term electro-
therapy in the context of this chapter will be used in its
broad, inclusive sense rather than as a strict definition of
the energy applied.
417
 Tidy’s physiotherapy
Scope
The aim of this chapter is to enable the reader to identify
the key issues in electrotherapy, using commonly employed
modalities as examples. It does not purport to fully
examine or explain the evidence for every modality, and
there are many ‘modalities’ that will hardly be mentioned.
This does not mean that they are unimportant or worth-
less: it is a realistic reflection of the complexity of modern
electrotherapy practice and the limits of what can be
achieved in a single chapter. Further details are available
in the standard texts (e.g. Robertson et al. 2006; Watson
2008b; Belanger 2010) and reference will be made in this
chapter to further useful research articles and resources. In
terms of clinical practice, the most widely used modalities
in the UK are ultrasound, IFT and TENS, with pulsed
shortwave with laser and neuromuscular electrical stimu-
lation (NMES) following close behind. Microcurrent
therapy, shockwave therapy, low intensity pulsed ultra-
sound (LIPUS) and some new radio frequency (RF) appli-
cations have been added to this chapter as evidenced and
emerging interventions.
MODEL OF ELECTROTHERAPY
Electrotherapy modalities follow a very straightforward
model that is presented below. The model (Figure 19.1)
identifies that the delivery of energy from a machine
or device is the starting point of the intervention. The
energy delivery to the tissues results in a change in one
or more physiological events – some of which are very
specific while others are multifaceted or more general.
The capacity of the applied energy to influence physio­
logical events is key to the process. The physiological
shift that results from the energy delivery is used in
practice to generate what is commonly referred to as
therapeutic effects.
The clinical application of the model is best achieved by
what appears to be a reversal of this process. Starting with
the patient and their problems, identified from the clinical
assessment, the treatment priorities can be established
and the rationale for the treatment determined. Having
established the therapeutic target (or aim), move one step
Theory
Treatment delivery
Dose calculation
Deliver
Physiological
energy effect(s)
Figure 19.1  A generic model of electrotherapy
(electrophysical agents).
418
back through the model and identify which physiological
events/processes need to be activated or stimulated in
order to achieve the outcome. Once the required physio-
logical changes have been identified, moving one step
further back will enable a modality decision to be made.
This is based on the existing evidence relating to which
modalities stimulate which physiological effects. If there
is no electrotherapy modality that is capable of achieving
the intended effects, then electrotherapy would have no
rational use in the management of this particular patient.
The effects of electrotherapy appear to be modality
dependent. This is a critical decision, in that each modality
has a limited subset of effects which are fundamentally
different from another modality. It is certainly not the case
that some modalities are universally ‘better’ than others
– it is the case that some modalities are more effective at
achieving particular therapeutic effects.
Having identified the modality that is best able to
achieve the effects required, the next clinical stage is to
make a ‘dose’ selection. Not only is it critical to apply the
right modality, but it needs to be applied at the appropri-
ate ‘dose’ in order for maximal benefit to be achieved.
There is a substantial and growing body of evidence that
the same modality can be applied at different doses and
the results will be different (Watson 2010). An example
might be the use of ultrasound energy. Applied at a low
‘therapeutic’ dose, it can stimulate tissue repair and
healing. Applied at a much higher dose (high intensity
focussed ultrasound (HIFU) ) it can be used to ablate
tumour tissue. The energy form is the same, but by varying
the applied ‘dose’ the outcome is clearly different.
One might argue that this is an extreme example, which
in some ways it is, but the point is that the effects of the
therapy are both modality- and dose-dependent. There are
‘therapeutic windows’ in electrotherapy (as there are in
almost all therapeutic interventions) and in order to
achieve the ‘best’ outcome, it is essential to get as close to
this window as one possibly can.
This fundamental model used to explain electrotherapy
could be applied to many interventions, including drug
therapy, manual therapy and exercise therapy. All involve
the use of an intervention in order to achieve a physiologi-
cal shift or change. It is this change that is the therapeutic
tool. The treatment is just a tool to stimulate the physio-
logical change and electrotherapy is therefore little differ-
ent from manual therapy or any other intervention except
that a ‘machine’ is employed as an initiator of the physi-
ological shift. It is a tool that when applied at the right
time at the right dose and for the right reason has the
Therapeutic capacity to be beneficial. Applied inappropriately, it is not
effect(s) at all surprising that is has the capacity to achieve nothing
or, in fact, to make things worse. The skilful practitioner
Patient uses the available evidence combined with experience to
make the best possible decision, taking into account the
psychosocial and holistic components of the problem – it
is not a simple reductionist solution.

THERAPEUTIC WINDOWS
Windows of opportunity are topical in many areas of
therapy and medical practice, and are not a new phenom-
enon. It has long been recognised that the ‘amount’ of a
treatment is a critical parameter. This is no less true for
electrotherapy than for other interventions. There are liter-
ally hundreds of research articles that illustrate that the
same modality applied at a different ‘dose’ will produce a
different outcome.
Given the research evidence, there appear to be several
aspects to this issue. Using a very straightforward model,
there is substantial evidence, for example, that there is
an amplitude or strength window. An energy delivered at
a particular amplitude has a beneficial effect while the
same energy at a lower amplitude may have no demon-
strable effect (too low) or a tissue destruction effect (too
high in therapy terms). Laser therapy offers an obvious
example: one level will produce a distinct cellular response
while a higher dose can be considered to be destructive.
Karu (1987) demonstrated and reported these principles
related to laser energy and the research produced since
have served to reinforce the concept (e.g. Vinck et al.
2003). Further examples of amplitude windows can be
seen easily in the work of Hill et al. (2002), Reher et al.
(2002), Miller and Gies (1998), Cleary (1987) and Pereira
et al. (2002), and have been more extensively reviewed in
Watson (2010).
Along similar lines, ‘frequency windows’ are also ap­­
parent. A modality applied at a specific frequency or
pulsing regime might have a measurable benefit, while
the same modality applied using a different pulsing
profile may not appear to achieve equivalent results.
Examples can be found in many articles, including
Young and Dyson (1990a), Young and Dyson (1990b)
and Sontag (2000).
Electrical stimulation frequency windows have been
proposed and there is clinical and laboratory evidence to
suggest that there are frequency-dependent responses in
clinical practice. TENS applied at frequency X appears to
have a different outcome to TENS applied at frequency
Y in an equivalent patient population. Studies by Sluka
et al. (2006), Han et al. (1991) and Palmer et al. (1999)
illustrate the point.
Assuming that there are likely to be more than two
variables to the real world model, some complex further
work needs to be invoked. There is almost certainly an
energy or time-based window (e.g. Hill et al. 2002) and
then another factor based on treatment frequency (number
of sessions a week or treatment intervals). Work continues
to identify the more and less critical parameters for each
modality across a range of clinical presentations and a
more detailed review of these concepts can be found in
Watson (2010).
Electrotherapy Chapter 19
ELECTROTHERAPY MODALITY
GROUPING
No matter which classification of the numerous electro-
therapy modalities is adopted, it can easily be criticised.
The groupings used in Figure 19.2 are one way of looking
at the scope of electrotherapy, although it is not presented
as the ‘right’ model.
The division into three main subgroups – electrical
stimulation, thermal modalities and non-thermal modali-
ties – is the theme that will be followed in this chapter.
The electrical stimulation modalities have a common mode
of action in that their primary effect will be on nerve
(and, in some circumstances, muscle) tissue. Commonly
employed forms of electrical stimulation include TENS,
IFT, various forms of muscle stimulation (e.g. NMES,
functional electrical stimulation (FES)) and many others
which will not be considered in any detail in this
chapter. Microcurrent therapy is ‘different’ in that its
primary mode of action is to influence tissue repair
rather than stimulate nerve, and thereby falls into an
overlap zone between categories.
The thermal modalities group includes various forms of
heating that have been used for many years in therapy,
including infrared therapy, conductive heating, wax
therapy, hot packs and the ‘deeper’ heating modalities –
shortwave diathermy (SWD), other RF applications and
microwave diathermy (MWD). The use of the heating
modalities has diminished in clinical practice over recent
years and much as some of the interventions employed in
the past may lack evidence, there are compelling reasons
to keep heat therapies in the clinical repertoire and there
are areas where the use of heat-based therapies is likely
to re-emerge as a strongly evidence-based intervention.
Examples of modern heat therapy applications include
Michlovitz et al. (2004), Usuba et al. (2006), Mayer et al.
(2006), and Leung and Cheung (2008).
The non-thermal modalities are grouped together on the
basis that if delivered at sufficiently high levels, any of
these modalities could produce a significant or even
destructive heating effect in the tissues. If they are deliv-
ered at sufficiently low dose, they are considered to be
‘non-thermal’ in their primary effect. This is somewhat
misleading in that any energy delivered to the tissues
which is subsequently absorbed will achieve a heating
effect. The non-thermal label is derived from the fact that
there is no gross thermal change and the patient is not
able to perceive a thermal effect. More properly, these
should possibly be referred to as microthermal or subthermal
modalities. Ultrasound, pulsed shortwave therapy (PSWT)
and laser therapy fall most obviously into this group, and
various forms of magnetic therapy which are gaining
ground in the literature would also be best suited to this
area, as would some of the developing low-power RF
419
 Tidy’s physiotherapy

Electrical Stimulation Thermal Agents/ Non-Thermal Agents/

Agents/Modalities Modalities Modalities

Transcutaneous Electrical Nerve Infrared Irradiation (IRR) [Pulsed] Ultrasound

Stimulation (TENS)
Interferential Therapy (IFT)
Neuromuscular Electrical
Stimulation (NMES)
Functional Electrical
Stimulation (FES)
Russian Stimulation
Diadynamic Therapy
Iontophoresis
H Wave Therapy: Action Potential
Stimulation (APS)
Rebox Therapy
High Voltage Pulsed Galvanic
Stimulation (HVPGS)
Microcurrent Therapy
Shortwave Diathermy (SWD)
Microwave Diathermy (MWD)
Other RF Therapies
Contact Heating
Hydrocollator Packs
Wax Therapy
Balneotherapy
(water/spa/whirlpool)
Mud (and associated) Therapy
Fluidotherapy
Ultrasound
Laser
Cryotherapy/Cold/
Ice/Immersion
Low Intensity Pulsed Ultrasound
(LIPUS)
[Pulsed] Shortwave Therapy
(PSWT)
[Pulsed] Laser Therapy
(LLLT/LILT)
Low Intensity RF Applications
Magnetic Therapies
Pulsed Magnetic Therapy
Static Magnetic Therapy
Induced Magnetic Therapy
Microcurrent Therapies

Figure 19.2  Electrotherapy (EPA) modalities classification.

applications. The current clinical use of these modalities
is primarily directed at enhancing the process of healing
and tissue repair. Ultrasound presents a dilemma in that
some practitioners use it as a modality which is employed
with the deliberate intention of heating the tissues,
although the evidence would support its ‘non-thermal’ use
over and above its thermal application. In the context of
this chapter, microcurrent therapy will be included in the
electrical stimulation section (though it could fall into
either group) and shockwave therapy will be included in
the non-thermal group in that it is an energy delivery
which is not intended as a thermal agent and is not an
electrical stimulation modality – thus illustrating that any
classification system fails at some point!
ELECTRICAL STIMULATION
MODALITIES
General principles of electrical
stimulation
The general principles of electrical stimulation (ES) in the
context of commonly employed electrotherapy modalities
focusses on the use of electrical currents (usually in the
form of discrete pulses) to initiate action potentials in
nerves. This would be true for modalities like TENS, NMES
in its various forms and interferential therapy (though
this modality does not employ discrete pulses). There are
other forms of intervention which employ alternative
mechanisms – one of which is iontophoresis (which uses
a direct or pulsed direct current to enhance the delivery
of a chemical substance or drug through the skin) and
microcurrent-type therapies which are delivered at a level
that is insufficient to stimulate a nerve action potential but
which do appear to have an effect on the repair responses
in wounds and damaged tissues.
Nerve action potentials
Assuming that the majority of ES modalities work by
means of nerve activation, a brief examination of how this
is achieved would be beneficial. A nerve in its resting state
is said to be ‘polarised’. When an action potential is trans-
mitted along a nerve, the membrane at the point of the
action potential is momentarily depolarised before return-
ing to its normal state (repolarisation). Essentially, the
employment of an electrical current or pulse is as a means
of initiating an action potential along the course of the
nerve. Once the action potential has been initiated by this
exogenous (external to the body) signal, then it will con-
tinue along the nerve (whether sensory or motor) in
the normal fashion: the electrical stimulator is simply an
initiator of the activity. If the nerve is stimulated ten times
a second, then there will be ten action potentials a second

420

initiated. If stimulated 100 times a second, predictably, it
will fire 100 times a second. There are some constraints to
this relationship based on refractory periods and thresh-
old potentials which are beyond the scope of this chapter
but are usefully reviewed in most standard electrotherapy
texts (Robertson et al. 2006; Watson 2008b).
The nerve being stimulated is largely unable to differ-
entiate between different types of electrical stimulation.
It is simply responding to an external stimulus and
will fire accordingly. The main difference between stimu-
lators is that they are set to have an optimal effect on
particular nerve types such that a TENS machine will be
the most efficient device to use to achieve stimulation of
a sensory nerve and a NMES device will be optimal in
stimulating motor nerves. TENS will, of course, stimulate
both sensory and motor nerves; however, it is more effi-
cient in having an effect on the sensory nerves. The same
would be true for a NMES stimulator – the effect is not
exclusively a motor one, it is just that the motor effect is
dominant.
Bearing these principles in mind, the commonly
employed ES modalities will be considered in brief with
their primary clinical applications described. There are
many alternative and additional widespread uses of these
modalities that are evidenced, but are beyond the scope
of this overview chapter. More comprehensive considera-
tions can be found in the references supplied, as well as
in the major texts.
Transcutaneous electrical nerve
stimulation (TENS)
TENS is a method of electrical stimulation which aims
primarily to provide a degree of pain relief (symptomatic)
by specifically exciting sensory nerves and thereby stimu-
lating either the pain gate mechanism and/or the opioid
system (Walsh 1997; Sluka and Walsh 2003; Johnson
2008). Strictly speaking, any form of electrical stimulation
applied with surface electrodes that stimulates nerves can
be referred to as TENS but in clinical practice the term is
most commonly employed in the context identified above.
The different methods of applying TENS relate to these
different physiological mechanisms. Success is not guaran-
teed with TENS. The percentage of patients who obtain
pain relief will vary, but would typically be in the region
of ≥70% for acute-type pains and ≥60% for more chronic
pains. Both of these are significantly ‘better’ than the
placebo effect.
The technique is non-invasive and has few side
effects when compared with drug therapy. Modern
TENS devices may be analogue (Figure 19.3a,b) or digital
(Figure 19.3c,d) in design. Although their outputs are
essentially the same, their control systems differ. TENS
is normally included in the multimodal stimulators
(Figure 19.3f). Most TENS applications are now made
Electrotherapy Chapter 19
using self-adhesive, pre-gelled electrodes (Figure 19.3e)
which have several advantages, including a lower allergy
incidence, a reduced cross-infection risk, easier application
and lower overall cost, although some practitioners retain
the older, impregnated carbon rubber electrode systems.
Specialist TENS variations include ‘maternity’ TENS
(Figure 19.3g), which have a simple to operate ‘boost’
function.
Machine parameters
The main parameters (or settings) on a TENS machine are
those that are influential in terms of sensory nerve stimula-
tion, which is the primary aim of the modality. The loca-
tion of these controls on typical analogue and digital TENS
machines is illustrated in Figure 19.4.
The current intensity (A) (strength) will typically be in
the range of 0–80 mA, though some machines may
provide higher outputs. Although this is a small current,
it is sufficient because the primary target for the therapy is
the sensory nerves and so long as sufficient current is
passed through the tissues to depolarise these nerves, the
modality can be effective.
The pulse rate (B) will normally be variable from about
1 or 2 pulses per second (pps) up to 200 pps or more. To
be clinically effective, it is suggested that the TENS machine
should cover a range of 2–150 Hz.
In addition to the stimulation rate, the duration (or
pulse width) of each pulse (C) may be varied from about
40 to 250 microseconds (µs). Recent evidence would
suggest that this is possibly a less important control than
the intensity and frequency. These are short duration
pulses which are effective because sensory nerves have a
relatively low threshold and will respond well to short
duration, rapidly changing pulses. There is generally no
need to apply a prolonged pulse in order to force the nerve
to depolarise.
Most modern machines will offer a BURST mode (D)
in which the pulses will be delivered in bursts or ‘trains’,
usually at a rate of 2–3 bursts per second. Finally, a modu-
lation mode (E) may be available which employs a method
of making the pulse output less regular and therefore
minimising the accommodation effects which are often
encountered with this type of stimulation.
Machines most commonly offer a dual channel
output, i.e. two pairs of electrodes can be stimulated
simultaneously. In some circumstances this can be a
distinct advantage, though it is interesting that most
patients and therapists tend to use just a single channel
application.
The pulses delivered by TENS stimulators vary between
manufacturers, but tend to be asymmetrical biphasic
modified square wave pulses. By employing biphasic
pulses it means that there is usually no net direct current
component, thus minimising any skin reactions owing to
the build up of electrolytes under the electrodes.
421
 Tidy’s physiotherapy

A B C

D F G

Figure 19.3  TENS machines and electrodes: (a) analogue TENS (Body Clock); (b) analogue TENS (Chatanooga); (c) digital TENS
(TensCare); (d) digital TENS (Natures Gate); (e) self-adhesive electrodes (TensCare); (f) multimodal stimulator including TENS
(Enraf); (g) obstetric/maternity TENS (Body Clock).

Mechanism of action
The type of stimulation delivered by the TENS unit
aims to excite (stimulate) the sensory nerves and, by
so doing, activate specific natural pain relief mecha-
nisms. For convenience, if one considers that there
are two primary pain relief mechanisms which can be
activated – the pain gate mechanism and the endoge­
nous opioid system – the variation in stimulation
parameters used to activate these two systems will be
briefly considered.

422
 Electrotherapy Chapter 19

Typical analogue Typical digital Traditional TENS (hi-TENS, normal TENS)

TENS device TENS device
Traditional TENS usually uses stimulation at a relatively
Output high frequency (80 or 90–130 Hz) and employs a rela-
intensity (A)
Mz
tively narrow pulse width (often used at about 100 µs
!
though, as identified above, there is less support for
!
manipulation of the pulse width in the current research
150 180 MODE 4
5 10
22
Pulse
literature and the use of a fixed pulse duration of around
120 210
3 70
90

frequency (B)
240
100
60
2 150

200 µs may be the most efficient). The stimulation is

30 270

PULSE WIDTH PULSE RATE

delivered at ‘normal’ intensity (see below). Thirty minutes

M
is probably the minimally effective time, but it can be
delivered for as long as needed. The main pain relief is
Burst (D) and
achieved during the stimulation, with a limited ‘carry over’
modulation
mode (E) effect, i.e. pain relief after the machine has been switched
TPN
300
controls off (Chesterton et al. 2002).

Pulse width Acupuncture TENS (lo-TENS, AcuTENS)

duration (C)
Figure 19.4  Typical analogue and digital TENS machine
controls.
Pain relief by means of the pain gate mechanism prima-
rily involves activation (excitation) of the Aβ sensory
fibres, thus reducing the transmission of the noxious stim-
ulus from the ‘c’ fibres through the spinal cord and on to
the higher centres. The Aβ fibres appear to respond pref-
erentially when stimulated at a relatively high rate (in the
order of 80 or 90–130 Hz). It is difficult to find support
for the concept that there is a single frequency that works
best for every patient, but this range appears to cover the
majority of individuals (Walsh 1997). This TENS mode is
delivered with high frequency (traditional/normal) TENS.
An alternative approach is to stimulate the Aδ fibres
which respond preferentially to a much lower rate of stim-
ulation (in the order of 2–5 Hz), which will activate the
opioid mechanisms and provide pain relief by causing the
release of an endogenous opiate (encephalin) in the spinal
cord which will reduce the activation of the noxious
sensory pathways (Han et al. 1991; Walsh 1997; Sluka
et al. 2006). This TENS mode is delivered with low-
frequency (acupuncture (AcuTENS) ) TENS.
A third possibility is to stimulate both nerve types at
the same time by employing a burst mode stimulation. In
this instance, the higher frequency stimulation output
(typically at about 100 Hz) is interrupted (or burst) at the
rate of about 2–3 bursts per second. When the machine is
‘on’, it will deliver pulses at the 100 Hz rate, thereby acti-
vating the Aβ fibres and the pain gate mechanism, but by
virtue of the rate of the burst, each burst will produce
excitation in the Aδ fibres, therefore stimulating the opioid
mechanisms. For some patients this is by far the most
effective approach to pain relief, though as a sensation,
numerous patients find it less acceptable than the other
forms of TENS.
When using AcuTENS, TENS is used at a lower stimulation
frequency (2–5 Hz) with longer duration pulses (200–
250 µs). The intensity employed will usually need to be
greater than with the traditional TENS – a definite, strong
sensation but still one that is not painful (see below). A
minimally useful stimulation of 30 minutes should be
delivered. It takes some time for the opioid levels to build
up with this type of TENS and hence the onset of pain
relief may be slower than with the traditional mode. Once
sufficient opioid has been released, however, it will keep
on working after cessation of the stimulation. Many
patients find that stimulation at this low frequency at
intervals throughout the day is an effective strategy. The
‘carry over’ effect may last for several hours in the clinical
setting, though timeframes of rather more limited dura-
tion have been demonstrated by Chesterton et al. (2002).
Brief intense TENS
Brief intense TENS is a mode that can be employed to
achieve rapid pain relief, but some patients may find the
strength of the stimulation too intense and will not
tolerate it for sufficient duration to make the treatment
worthwhile. The pulse frequency applied is high (in the
90–130 Hz band) and the pulse width is also high
(≥200 µs). The current is delivered at, or close to, the toler-
ance level for the patient such that they would not want
the machine turned up any higher. In this way, the energy
delivery to the patients is relatively high when compared
with the other approaches. It is suggested that 15–30
minutes at this stimulation level is the most that would
normally be used. Pain relief onset is rapid and marked
if the patient can cope with the stimulation intensity
(Walsh 1997; Sluka and Walsh 2003).
Burst mode TENS
As described above, the machine is set to deliver tradi-
tional TENS, but the burst mode is switched in, therefore

423
 Tidy’s physiotherapy
interrupting the stimulation outflow at rate of 2–3 bursts/
second. The stimulation intensity will need to be relatively
high – not as high as the brief intense TENS but similar
to that applied in AcuTENS.
Frequency selection
With all of the above mode guides, it is probably inap-
propriate to identify very specific frequencies that need to
be applied to achieve a particular effect. If there was a
single frequency that worked for everybody, it would be
much easier, but the research does not support this
concept. The patient (or the therapist) needs to identify
the most effective frequency for their pain and manipula-
tion of the stimulation frequency dial or button is the best
way to achieve this. Patients who are told to leave the dials
alone are less likely to achieve optimal effects. Frequency
ranges within which the ‘ideal’ is likely to be found
are those identified above. Some TENS devices do not
enable control of specific pulse rate and duration settings,
but instead offer ‘automatic’ programmes that effectively
deliver some of each of the effective modes. This can be
considered advantageous (that the patient has less to
worry about on the machine) but others consider it a
broad brush approach and the amount of time spent at
the optimal setting for the patient is minimal; hence, it
may, in fact, be ineffective. There is currently no published
evidence that supports the ‘bit of everything’ approach in
the clinical environment.
Stimulation intensity
It is not possible to describe the treatment current strength
in terms of how many (milli)amps should be applied. The
most effective intensity management appears to be related
to what the patient feels during the stimulation and this
may vary from session to session, though will tend to be
fairly consistent for any individual patient. As a general
guide, it appears to be effective to go for a ‘definitely there
but not painful’ level for the normal (high) TENS and a
‘strong but not painful’ level for the acupuncture (low)
mode (Sluka and Walsh 2003). Figure 19.5 illustrates
these settings on a ‘subjective’ scale. Some evidence (e.g.
Bjordal et al. 2003; Aarskog et al. 2007) suggests that
stronger stimulation might be more effective for clinical
pain states.
Electrode placement
In order to get the maximal benefit from the modality,
target the stimulus at the appropriate spinal cord level
(appropriate to the pain). Placing the electrodes either side
of the lesion – or painful areas – is the most common
mechanism employed to achieve this. There are many
alternatives that have been researched and found to be
effective – most of which are based on the appropriate
nerve root level/spinal cord segment:
424
No Definite Painful
sensation sensation sensation
Just Strong Maximum
sensation sensation tolerance
High Low
TENS TENS
Figure 19.5  Stimulus strength for TENS clinical application.
• stimulation of appropriate nerve root(s);
• stimulate the peripheral nerve (proximal to the
pain);
• stimulate motor point (innervated by an appropriate
nerve root level);
• stimulate trigger point(s) or acupuncture point(s);
• stimulate the appropriate dermatome, myotome or
sclerotome.
It is beyond the scope of this chapter to detail specific
electrode combinations for specific clinical problems and,
in any case, would probably be inappropriate to do so.
The TENS literature covers electrode placement in some
detail and the interested reader is referred to useful specific
texts in this context (Walsh 1997; Johnson 2008).
If the pain source is vague, diffuse or particularly exten-
sive both channels can be employed simultaneously. A
two-channel application can also be effective for the man-
agement of a local plus a referred pain combination, with
one channel used for each component. Most standard
machines do not allow different stimulation parameters
to be set for each channel, though there are some devices
that will allow this possibility, for example channel A on
low frequency, opioid setting and channel B on higher
frequency pain gate setting.
Numerous systematic and Cochrane Reviews have been
published relating to the application of TENS for several
different clinical pain groups (e.g. Rutjes et al. 2009; Walsh
et al. 2009). Many of these come to an ‘inconclusive’ con-
clusion, though this may be related to dose-related issues
(therapeutic windows) (Johnson and Martinson 2007;
Watson 2010) and methodological limitations of the
research rather than the failure of TENS to have a signifi-
cant effect.
Interferential therapy (IFT)
The basic principle of IFT is to utilise the strong physio-
logical effects of low frequency (≅<250 pps) electrical
 Electrotherapy Chapter 19

A
B

Figure 19.6  Mains-powered interferential devices. (a) IFT device (EMS Physio); (b) IFT available on a general electrical
stimulation device (Enraf).

stimulation of muscle and nerve tissues without the asso-

ciated pain encountered with low frequency stimulation
(Watson 2000; Palmer and Martin 2002).
IFT is delivered using either dedicated main s-powered
interferential devices (Figure 19.6), portable (battery-
powered) devices (Figure 19.7) or multimode units that
include IFT stimulation among several other treatment
modes (Figure 19.8).
To produce low frequency effects at sufficient intensity
at depth, patients may experience considerable discomfort
in the superficial tissues (i.e. the skin). This is a result of
the compound impedance of the skin being inversely pro-
portional to the frequency of the stimulation. The result
of applying this higher frequency is that it will pass more
easily through the skin, requiring less electrical energy
input to reach the deeper tissues and giving rise to less
discomfort.
The effects of tissue stimulation with these ‘medium
frequency’ currents (medium frequency in electromedical
terms is usually considered to be 1 kHz–100 kHz) is not
fully understood and while it is likely to have an effect, Figure 19.7  Portable (battery-powered) IFT device (TensCare).
little detail is currently known though it is assumed not to
directly stimulate nerve. Ward (2009) recently reviewed
the key issues with medium frequency currents.
Interferential therapy utilises two of these medium fre-
quency currents, passed through the tissues simultane-
ously, where they are set up so that their paths cross and

425
 Tidy’s physiotherapy

Figure 19.8  Examples of multimode units that include IFT: (a) Gymna; (b) Chatanooga; (c) Uniphy.

they literally interfere with each other. This interference A B

gives rise to an interference (beat frequency) which has the
characteristics of low frequency stimulation. In effect
the interference mimics a low frequency stimulation in
the cross over (interference) zone.
The exact frequency of the resultant interference (or beat
frequency) can be controlled by the input frequencies. If,
for example, one current was at 4000 Hz and its compan- B A
ion current at 3900 Hz, the resultant beat frequency would
be at 100 Hz carried on a medium frequency 3950 Hz Figure 19.9  Basic principles of interferential current
amplitude modulated current (Figure 19.9). production.
By careful manipulation of the input currents it is pos-
sible to achieve any beat frequency that is needed clini- The use of two-pole IFT stimulation is made possible by
cally. Modern machines usually offer beat frequencies of electronic manipulation of the currents – the interference
1–150 Hz, though some offer a choice of up to 250 Hz or occurs within the machine instead of in the tissues. There
more. Some machines offer a range of ‘carrier’ frequencies, is no known physiological difference between the effects
i.e. other than 4000 Hz. The evidence would suggest that of IFT produced with two- or four-electrode systems; in
the higher the carrier frequency, the less discomfort will fact, the pre-modulated currents can be considered supe-
be experienced by the patient and therefore where there is rior in clinical effectiveness terms (e.g. Ozcan et al. 2004).
a choice, the higher carrier frequency should be employed. The key difference is that with a four-pole application the

426

interference is generated in the tissues and with a two-pole
treatment, the current is ‘pre-modulated’, i.e. the interfer-
ence is generated within the machine unit.
Whichever generation system is employed, the treat-
ment effect is generated from low frequency stimulation,
primarily involving the peripheral nerves. Low frequency
nerve stimulation is physiologically effective (as with
TENS and NMES) and this is the key to IFT intervention.
Frequency sweep
Nerves will accommodate to a constant signal and a
sweep (or gradually changing frequency) is often used
to overcome this problem. The principle of using the
sweep is that the machine is set to automatically vary the
effective stimulation frequency using either pre-set or
user-set sweep ranges. The sweep range employed should
be appropriate to the desired physiological effects (see
below). It has been repeatedly demonstrated that ‘wide’
sweep ranges are ineffective in the clinical environment.
The clinical advantage of the sweep treatment application,
beyond that of minimising the accommodation effects,
are that a range of treatment frequencies can be automati-
cally applied (Watson 2000).
Clinical note
Care needs to be taken when setting the sweep on a
machine in that with some devices the user sets the
actual base and top frequencies (e.g. 90 and 130 Hz)
and with other machines the user sets the base
frequency and then how much needs to be added for
the sweep (e.g. 90 and 40 Hz).
The pattern of the sweep makes a significant difference
to the stimulation received by the patient. Most machines
offer several sweep patterns, though there is very limited
‘evidence’ to justify some of these options. In the classic
‘triangular’ sweep pattern, the machine gradually changes
from the base to the top frequency, usually over a time
period of six seconds, though some machines also offer
one- or three-second options. In the example illustrated
(Figure 19.10), the machine is set to sweep from 90 to
130Hz
90Hz
Time
Figure 19.10  90–130 Hz triangular frequency sweep pattern
with IFT.
Electrotherapy Chapter 19
130 Hz, employing a triangular sweep pattern. All fre-
quencies between the base and top frequencies are deliv-
ered in equal proportion.
Other patterns of sweep can be produced on many
machines, for example a rectangular (or step-like) sweep.
This produces a very different stimulation pattern in that
the base and top frequencies are set, but the machine then
‘switches’ between these two specific frequencies rather
than gradually changing from one to the other. Figure
19.11 illustrates the effect of setting a 90–130 Hz rectan-
gular sweep.
There is a clear difference between these examples, even
though the same ‘numbers’ are set: one will deliver a full
range of stimulation frequencies between the set frequency
levels and the other will switch from one frequency to the
other. There are numerous other variations on this theme
and the ‘trapeziodal’ sweep (Figure 19.12) is effectively a
combination of these two.
The only sweep pattern for which ‘evidence’ appears to
exist is the triangular sweep. The others are perfectly safe
to use, but whether they are clinically effective or not
remains to be shown.
Physiological effects and clinical applications
It has been suggested that IFT works in a ‘special way’
because it is ‘interferential’ as opposed to ‘normal’ stimu-
lation. The evidence for this special effect is lacking
and it is most likely that IFT is just another means
by which peripheral nerves can be stimulated. Many
regard it as more acceptable than other forms of electrical
stimulation as it generates less (skin) discomfort (e.g
Shanahan et al. 2006).
130Hz
90Hz
Time
Figure 19.11  90–130 Hz rectangular frequency sweep
pattern with IFT.
130Hz
90Hz
Time
Figure 19.12  90–130 Hz trapezoidal frequency sweep
pattern with IFT.
427
 Tidy’s physiotherapy
The clinical application of IFT therapy is based on
peripheral nerve stimulation (frequency) data, though it
is important to note that much of this information has
been generated from research with other modalities, and
its transfer to IFT is assumed, rather than proven. There is
a lack of IFT-specific research compared with other modal-
ities (e.g. TENS, NMES).
The are four main clinical applications for which IFT
appears to be used:
• pain relief;
• muscle stimulation;
• increased local blood flow;
• reduction of oedema.
In addition, claims are made for its role in stimulating
healing and repair, though they are not specifically covered
in this section. As IFT acts primarily on nerve, the strongest
effects are likely to be those which are a direct result of
such stimulation (i.e. pain relief and muscle stimulation).
The other effects are more likely to be secondary conse-
quences of these.
Pain relief
Electrical stimulation for pain relief has widespread clini-
cal use, though the direct research evidence for the use
of IFT in this role is limited. Logically one could use
the higher frequencies (90–130  Hz) to stimulate the pain
gate mechanisms and thereby mask the pain symptoms.
Alternatively, stimulation with lower frequencies (2–5  Hz)
can be used to activate the opioid mechanisms, again
providing a degree of relief. These two different modes
of action can be explained physiologically and will have
different latent periods and varying duration of effect
(same as for TENS). It remains possible that pain relief
may be achieved by stimulation of the reticular forma-
tion at frequencies of 10–25  Hz or by blocking C fibre
transmission at >50  Hz. Although both of these latter
mechanisms have been proposed with IFT, neither have
been categorically demonstrated (Palmer and Martin
2008).
A good number of studies (e.g. Johnson and Tabasam
2003; Hurley et al. 2004; McManus et al. 2006; Jorge
et al. 2006; Walker et al. 2006; Lau et al. 2008; Fuentes
et al. 2010) provide substantive evidence for a pain relief
effect of IFT.
Muscle stimulation
Stimulation of the motor nerves can be achieved with a
wide range of frequencies. Clearly, stimulation at low fre-
quency (e.g. 1 Hz) will result in a series of twitches, while
stimulation at 50 Hz will result in a tetanic contraction.
There is limited evidence at present for the ‘strengthening’
effect of IFT (evidence does exist for some other forms of
electrical stimulation), though the article by Bircan et al.
(2002) suggests that it might be a possibility. On the basis
428
of the current evidence, the contraction brought about by
IFT is no ‘better’ than would be achieved by active exercise,
though there are clinical circumstances where assisted con-
traction is beneficial. For example, to assist the patient to
appreciate the muscle work required (similar to surged
Faradism used previously, but much less uncomfortable).
For patients who cannot generate useful voluntary contrac-
tion, IFT may be beneficial as it would be for those who,
for whatever reason, find active exercise difficult. There is
no evidence that has demonstrated a significant benefit of
IFT over active exercise. The choice of treatment parame-
ters will depend on the desired effect. The most effective
motor nerve stimulation range with IFT appears to lie
between approximately 10 and 20 Hz (maybe between 10
and 25 Hz).
Caution should be exercised when employing IFT as a
means to generate clinical levels of muscle contraction
in that the muscle will continue to work for the duration
of the stimulation period (assuming sufficient current
strength is applied). It is possible to continue to stimulate
the muscle beyond its point of fatigue and short stimula-
tion periods with adequate rest is probably a preferable
option. Some IFT devices are capable of generating a
‘surged’ stimulation mode which might be advantageous
in that fatigue would be minimised – this surged interven-
tion would be similar to, but more comfortable than,
Faradism.
Blood flow
There is very little, if any, quality evidence demonstrating
a direct effect of IFT on local blood flow changes. Most of
the work that has been done involves laboratory experi-
mentation on animals or asymptomatic subjects, and
most blood flow measurements are superficial, i.e. skin
blood flow. Whether IFT is actually capable of generating
a change (increase) in blood flow at depth remains ques-
tionable. The elegant study by Noble et al. (2000) demon-
strated vascular changes at 10–20 Hz, though they were
unable to identify clearly the mechanism for this change.
The stimulation was applied via suction electrodes and the
outcome could, therefore, be a result of the suction rather
than the electrical stimulation, though this is largely
negated by virtue of the fact that other stimulation fre-
quencies were also delivered with the suction electrodes
without significant flow changes. The most likely mecha-
nism therefore is via muscle stimulation effects (IFT
causing muscle contraction which brings about a local
metabolic and thus vascular change). The possibility that
the IFT is acting as an inhibitor of sympathetic activity
remains a theoretical possibility rather than an established
mechanism.
Based on current available evidence, the most likely
option for IFT use as a means to increase local blood
flow remains via the muscle stimulation mode; thus,
the 10–20 or 10–25 Hz frequency sweep appears to be
preferable.
 Electrotherapy Chapter 19

Figure 19.13  IFT rubber and sponge pad electrode system Figure 19.14  IFT Vacuum electrode system (Gymna).
(Gymna).

Oedema while it is useful, especially for larger body areas like the
shoulder girdle, trunk, hip and knee, it does not appear to
IFT has been claimed to be effective as a treatment to
provide any therapeutic advantage over pad electrodes.
promote the reabsorption of oedema in the tissues. Again,
Care should be taken with regard to the maintenance of
the published, as opposed to the anecdotal, evidence is
electrodes, electrode covers and associated infection risks
very limited in this respect and the physiological mecha-
(Lambert et al. 2000).
nism by which it could be achieved as a direct effect of IFT
Electrode positioning should ensure adequate coverage
remains to be established. The preferable clinical option
of the area for stimulation. In some circumstances, a
in the light of the available evidence is to use the IFT to
bipolar method is preferable if a longitudinal zone
bring about local muscle contraction(s) which, combined
requires stimulation rather than an isolated tissue area.
with the local vascular changes, could be effective in
Placement of the electrodes should be such that a cross­
encouraging the reabsorption of tissue fluid. The use of
over effect is achieved in the desired area (when using the
suction electrodes may be beneficial, but also remains
four-pole application).
unproven in this respect.
Treatment times vary widely according to the usual
A study by Jarit et al. (2003) demonstrated a change in
clinical parameters of acute/chronic conditions and the
oedema following knee surgery in an IFT group; however,
type of physiological effect desired. In acute conditions,
a study by Christie and Willoughby (1990) failed to dem-
shorter treatment times of ten minutes may be sufficient
onstrate a significant benefit on ankle oedema following
to achieve the effect. In other circumstances, it may be
fracture and surgery. The treatment parameters employed
necessary to stimulate the tissues for 20–30 minutes. It is
are unlikely to be effective given the information now
suggested that short treatment times are adopted initially,
available. If IFT has a capacity to influence oedema, the
especially with acute cases in the event of symptom
current evidence and physiological knowledge would
exacerbation. These can be progressed if the aim has not
suggest that a combination of pain relief (allowing more
been achieved and no untoward side effects have been
movement), muscle stimulation (above) and enhanced
produced. There is no research evidence to support the
local blood flow (above) is the most likely combination
continuous progression of a treatment dose in order to
to be effective and thus 10–20 Hz stimulation around the
increase or maintain its effect.
largest local muscle group is probably the most effective
approach.
Muscle stimulation modalities
Historically, motor nerve stimulation in order to generate
Treatment parameters muscle contraction was a widely employed modality, most
Stimulation can be applied using several different elec- commonly in the form of Faradism. More recently, this
trode systems (Figures 19.13 and 19.14). Pad electrodes intervention has fallen somewhat ‘out of favour’. There are,
and sponge covers are commonly employed; electrocon- in fact, still circumstances where it could be of significant
ductive gel is an effective alternative. The sponges should benefit, but in clinical practice using IFT (preferably in a
be thoroughly wet to ensure even current distribution. surged mode) is probably a more effective means to the
Self-adhesive pad electrodes are also available (similar to same end.
the newer TENS electrodes) and in the view of many prac- There has been a significant increase in the use of port-
titioners make IFT application easier. The suction electrode able or mains-powered muscle stimulators which are effec-
application method has been in use for several years and tively the modern replacement for Faradism. Figure 19.15

429
 Tidy’s physiotherapy

D E

Figure 19.15  (a–c) Battery-powered (portable) muscle stimulators, all of which will deliver muscle-stimulating currents:
(a) NMES stimulator (TensCare); (b) NMES stimulator (Body Clock); (c) IntelliSTIM (Natures Gate); (d) multimodal mains-powered
device – part of MediLink (EMS Physio); (e) stimulator with dedicated knee sleeve electrode system (BMR Neurotech).

430

illustrates examples of dedicated battery-powered and
multimodal mains-powered devices.
There is a growing range of chronic (meaning ‘not short-
term’) electrical stimulation devices that are aimed at
stimulating the motor nerve and hence bringing about
muscle activity/contraction. This form of therapy goes by
several names, but the most commonly applied are neu-
romuscular electrical stimulation (NMES), chronic NMES
and neuromuscular stimulation (NMS). NMES is probably
the preferred generic term.
It is suggested, with a growing body of evidence,
that gains in strength, endurance capacity and function
can be achieved with these types of stimulation. Much of
the early work has been conducted in laboratory
studies and also with athletes rather than typical patient
groups. There are recent articles, however, that have
demonstrated significant clinical benefit with patient
groups, including strengthening of peripheral muscula-
ture (Talbot et al. 2003; Callaghan and Oldham 2004;
Stevens et al. 2004; Lyons et al. 2005), work with shoul-
der problems in stroke patients (Chantraine et al. 1999;
Ada and Foongchomcheay 2002), chronic obstructive
pulmonary disease (COPD)/cardiac patients (Neder et al.
2002; Zanotti et al. 2003; Vivodtzev et al. 2006) and
various forms of incontinence (Indrekvam et al. 2001;
Amaro et al. 2003; Barroso et al. 2004). Useful reviews
of this field of intervention are included in McDonaugh
(2008), Robertson et al. (2006) and Lake (1992).
A further whole branch of neuromuscular-based stimu-
lation is the so called functional electrical stimulation
(FES). In this branch of electrotherapy, the explicit intent
of the stimulation is to achieve controlled muscle activa-
tion in order to facilitate some aspect of functional activity.
The range of applications is growing swiftly, especially
with the recent advances in computer-controlled stimula-
tors. One of the early, and most successful areas, is the
dropped foot stimulator (Taylor et al. 1999; Sheffler et al.
2006) which assists patients – most often following a
stroke – to achieve ankle dorsiflexion during the swing
phase of gait utilising stimulation of the anterior tibial
nerve. Modern devices incorporate a range of foot switches
or pressure detectors which enable stimulation to be active
at exactly the right part of the gait cycle (Figure 19.16).
Other forms of FES include standing and gross walking
activity with paraplegic patients which is also making sig-
nificant gains with computerised control systems.
Microcurrent therapy
Microcurrent therapy is becoming increasingly employed
in the clinical environment as a new and emerging
modality (though, in fact, it is neither new nor emerging
– it has strong published evidence dating back several
decades).
It is interesting in that it appears to break all the
classification ‘rules’ that were identified earlier in the
Electrotherapy Chapter 19
Figure 19.16  Odstock dropped foot stimulator. Salisbury
ODFS111 stimulator, innersoles, footswitch, electrode pads
and leads. The stimulator is a single channel device designed
primarily for gait assistance. (Courtesy of the Department of
Clinical Science and Engineering, Salisbury District Hospital, UK.)
chapter. It is not delivered with the intention of stimu-
lating nerves, but rather plays to the bioelectric environ-
ment of the tissues, and therefore has a primary effect
in terms of tissue repair (Watson 2006a; Poltawski and
Watson 2009). The general characteristics of this type of
therapy are that they utilise a direct current (pulsed or
continuous) delivered at a very low amplitude (literally
in the microamperage (millionths of an Amp) range)
which is usually subsensory from the patient perspective.
This type of therapy has already been shown to be effec-
tive in several clinical areas – most notably fracture repair
(Simonis et  al. 2003; Ciombor and Aaron 2005) and
healing of open wounds (Watson 1996; Evans et  al. 2001;
Watson 2008a) though soft tissue repair research is now
evolving and showing strong future potential. The use
of this therapy in tissue injury treatment has been
reviewed recently (Poltawski and Watson 2009).
Microcurrent therapy devices appear to be most
effectively employed when used for hours a day (rather
than minutes a week in the clinic) and therefore home-
based therapy with small, inexpensive, portable devices
(Figure 19.17) is a likely way forward. Microcurrent
therapy can, of course, be delivered using mains-powered
and multimodal devices (e.g. Chatanooga Intelect and
Gymna 400) and it has yet to be clearly determined
whether the small portable battery-powered home-based
machines or the clinic-based ones will become the most
widely employed.
Other forms of electrical stimulation
There are probably more ‘new’ electrical stimulation-type
devices that come out in a year than in any other area of
electrotherapy. Many of them are actually based on one of
the three main areas identified in previous sections (TENS,
IFT or NMES), though there are, of course, machines that
do, indeed, deliver a ‘different’ form of stimulation and
others that are simply a variation on a theme or a combi-
nation of themes.
431
 Tidy’s physiotherapy

In addition, combination therapy involves the simulta-

neous delivery of ultrasound and IFT, thereby achieving
the effects of both modalities, though there is no evidence
that any additional effects will occur by using this combi-
nation approach. Ultrasound is sometimes combined with
other electrical stimulation modes (e.g. diadynamic cur-
rents, TENS).
It is not possible in a general chapter such as this to
identify all the possible combinations and variations. The
interested reader might try investigating the major texts in
the area (Robertson et al. 2006; Watson 2008b; Belanger
2010). Try the current literature (though many of these
‘new’ devices are yet to have specific research published
with regard to their efficacy) or utilise web-based resources
(though as with any web-based material, one needs to be
both critical and selective with regards the information
accepted).

THERMAL MODALITIES

Introduction
A
Thermal-based treatments have been popular in the past
and have somewhat lost favour in more recent times,
being considered old fashioned and ineffective. There is
little doubt that the application of heat to the body tissues
generates significant physiological effects (Lehmann 1982;
Michlovitz 1996; Watson 2008b; Belanger 2010), and
applied with good reason and utilising the appropriate
forms of thermal energy (contact or induction methods)
is capable of being useful in therapy.

Principles of thermal treatments

The general principles of heat transfer to the body are well
B covered in the standard texts, and only a brief summary
will be included here. Essentially, thermal energy can
be applied using contact methods (hydrocollator or
hot packs, wax therapy), by using radiant heat sources
(infrared) or by applying electromagnetic energy which
is absorbed in the tissues resulting in heat generation
(e.g. shortwave, other RF and microwave therapies).
Some modalities (e.g. laser and ultrasound) can gener-
ate heating effects if applied at sufficient energy levels, but
these modalities appear to be more effective in the clinical
environment when applied at ‘non-thermal’ levels and so
are considered in the next section.

Therapeutic effects of heating

C therapies
Figure 19.17  Microcurrent therapy battery-powered, The effects of tissue heating can be effectively described in
portable devices. (a) Alpha Stim microcurrent stimulator;   general terms rather than repeating the same information
(b) Tendon Works microcurrent stimulator (Synapse);   in subsequent sessions. These effects are described and
(c) Elexoma microcurrent device.

432

evidenced in much more detail in specialist texts (Lehmann
1982; Michlovitz 1996; Watson 2008b), but are summa-
rised below for quick reference. Those effects listed
are considered to be local rather than systemic effects.
Systemic effects are usually minor in relation to the thera-
peutic application of heat and are detailed in the same
sources as identified above.
• Increased metabolic activity of cells/tissues.
• Increased local blood flow (volume).
• Increased collagen extensibility.
• Reduction in local muscle tone.
• Reduced pain perception.
• (Possible) increased rate of tissue healing (almost
certainly a secondary effect related to increased
metabolic rate and local blood flow changes).
Infrared radiation
Infrared is one of the least used heat modalities in modern
practice. The radiation is delivered using luminous (com-
bined infrared and visible red radiation) or non-luminous
(infrared only) sources, but whichever one is employed,
the effective penetration depth of the electromagnetic
energy is a matter of 1 or 1.5 mm at best and, hence, is a
very superficial form of heating. It is argued that even
though the heat is only generated in the superficial tissues,
the effect in terms of pain relief is significant, as many
sensory nerve endings are found in these tissues and, when
stimulated, they can be used to achieve pain relief by
means of the pain gate mechanism. Furthermore, the
heating of superficial tissues gives rise to local increases
in blood flow which can, in turn, provide reduction in
pain by increasing the absorption of inflammatory metab-
olites, decreasing local muscle spasm, encouraging the
reabsorption of oedema and possibly increasing tissue
repair by means of metabolic stimulation. Whether these
effects are of sufficient magnitude to be of clinical
value remains controversial, though there is little doubt
that the local application of such superficial heat does
give rise to (symptomatic) pain relief and the patients
often report a benefit as a result (Kitchen and Partridge
1991; Watson 2008b).
Wax therapy
In a similar way to infrared therapy, wax therapy has
become far less widely used than in the past, with the
exception of some specialist applications, most notably
in hand therapy and peripheral nerve lesion rehabilitation
(e.g. Ayling and Marks 2000; Brosseau et  al. 2002).
In principle, the melted wax is applied to the part
to be treated either using a ‘dunk’ technique in which the
hand or foot, for example, is repeatedly dunked into a
bath of moulten wax at around 45–50°C. Each layer
of wax being allowed to cool slightly before the next
Electrotherapy Chapter 19
is applied. Alternatively, the wax can be applied using a
bandage application or ladled on to the part to be treated.
As the wax solidifies from its melted state, thermal
energy is released (latent heat) which is subsequently
transferred to the superficial tissues. Tissue temperatures
can be raised by a useful 3–4°C to a depth of possibly up
to 2 cm, therefore providing a ‘deeper’ treatment effect
than infrared therapy, for example.
In addition to the direct heating effect, it is argued that
the deeper tissues will also heat up as a result of the con-
duction of thermal energy from the superficial tissues. The
applied wax also contains a variety of oils which have
beneficial effects in terms of improving skin condition and
facilitating exercise and massage therapies that usually
follow the wax treatment.
It is suggested that a similar heating level can be achieved
in the tissues using a hot pack (following section) or
hot water immersion, but many patients find that the
application of therapeutic wax has perceived benefits
over and above the heat part of the treatment, and will
certainly prefer it as a form of therapy to other forms of
heating – this appears to be especially true for patients
with long-term or chronic conditions, low grade, chronic
inflammatory conditions and non-acute degenerative
joint problems.
Further details are available in most standard elec­
trotherapy or thermal therapy texts (Lehmann 1982;
Michlovitz 1996; Robertson et al. 2006; Belanger 2010).
Hot packs
Hot packs used in therapy go by several names, but are
most commonly known as hydrocollator packs or simply
hot packs. This type of heat application is sometimes
referred to as ‘moist’ heat in that the pack is heated by
immersion in hot (70°C) water to bring the pack up to
therapeutic temperature. The pack is wrapped, typically in
towelling prior to placing against the skin of the patient.
The skin surface temperature of the wrapped pack will be
significantly lower than the 70°C owing to the insulating
nature of the towels, which are essential as these packs
should never be applied directly to the skin surface.
The tissue temperature rises associated with hot pack
therapy are of sufficient magnitude to achieve changes in
the ‘therapeutic range’ (Lehmann 1982), and will produce
sufficient heating to be of clinical value down to a depth
of at least 2–3 cm.
Treatment durations of 15–20 minutes appear to be
clinically effective and the rise in tissue temperature will
achieve effects in common with other thermal modalities.
Shortwave and microwave
diathermy
Both continuous shortwave diathermy (SWD) and cer-
tainly microwave diathermy (MWD) have shown a
433
 Tidy’s physiotherapy
significant reduction in clinical popularity in recent years
(Pope et al. 1995). Recent surveys have shown (e.g. Shah
et al. 2007; Chipchase et al. 2009) that almost no depart-
ments in Australia or the UK routinely use microwave
diathermy, and most departments and practices do not
even have the machines available. Continuous short-
wave, once a highly utilised modality, has also undergone
a reduction in clinical use, though many departments
do still have the equipment available (Al Mandeel and
Watson 2006).
Both modalities bring about tissue heating by means
of the introduction of electromagnetic energy into the
tissues, and tissue temperature rises occur as a result of
increased molecular activity – it is an indirect form of
heating (as opposed to the conductive type heating
described previously).
SWD utilises a high frequency (around 27 MHz) of
electromagnetic energy which is applied either using ca­­
pacitor plate-type electrodes or a monode/drum applica-
tor. Although attached to the same treatment unit, each of
these electrode types brings about heating in a slightly
different way and, importantly, there is a fundamental
difference in the type of tissues in which the heat is
produced.
The interested reader is referred to the detail in electro-
therapy texts but, in summary, the capacitor plate-type
application results in high frequency energy being deliv-
ered to the tissues (electrostatic). Dissipation of this
energy is primarily in the tissues of high impedance, thus
a very high proportion of the heating effect is generated
in the skin, fat and other ‘insulating’ superficial tissues.
The previous claims that this was a deep form of heating
is questionable and in terms of current clinical application
its demise is probably appropriate.
The alternative mode of application employs the
monode or drum applicator (as per PSWT). The energy
delivered from this type of applicator is effectively an elec-
tromagnetic (as opposed to electrostatic) field, oscillating
at high frequency. The delivered energy is primarily
absorbed in the tissues of low impedance (such as muscle,
nerve, tissue where there is significant water content) and
it is here that the most significant heating effects are
achieved.
It is suggested that when applying continuous short-
wave in the clinical environment, with the deliberate
intention of heating the tissues, the monode or drum
applicator should routinely be used unless the primary
tissue in which the heating is desired is the skin or super-
ficial fat layers.
Other radio frequency (RF) therapies
There has been a recent upsurge in the use of various RF
energy applications at frequencies other than those classi-
cally employed for shortwave and microwave treatments.
Delivery of these energies either via a capacitive coupling
434
Figure 19.18  Example of a radio frequency treatment device
(Indiba).
or resistive coupling system appears to generate significant
tissue heating and these effects appear to be achieved at
some reasonable depth. The anecdotal and early experi-
mental evidence is generally supportive but, as yet, there
are no substantive comparative trials (i.e. comparing the
efficacy of these new applications with existing thermal
treatments) to enable a clinical effectiveness judgement to
be made. Work is in progress and it may transpire that RF
applications at frequencies other than those historically
employed in therapy are more effective, and a shift in
clinical delivery systems may therefore be justified. The
machines that deliver the RF energy at relative high doses
can also be employed in ‘low dose’ mode, achieving clini-
cal effects more in line with the ‘non-thermal’ modalities
described in the next section. Establishing whether the
high or low energy modes are more effective than other
therapies in these sections is ongoing. An examples of RF
treatment equipment is illustrated in Figure 19.18.
NON-THERMAL MODALITIES
Introduction
There has been a significant debate in recent years with
regard to the potential for various electrotherapy modali-
ties to have their primary mode of action by means of
‘non-thermal’ effects. There is a growing body of evidence
that supports the contention that it is not necessary to
provide sufficient energy to actually ‘heat’ the tissues in
order to generate therapeutic benefit. Modalities such as
ultrasound, shortwave, RF, laser and microwave therapies,
when applied at sufficiently low intensity, appear to bring
about significant clinical effects without generating per-
ceptible thermal change. This is a difficult area as when
any energy is delivered to the body and absorbed in suf-
ficient quantity, there will be some thermal effect. What is
generally meant by the clinical term ‘non-thermal’ is that
neither the patient nor the therapist are able to detect any
significant (gross) temperature change.
 Electrotherapy Chapter 19

Various authors have argued that the therapeutic bene-

fits of generating tissue ‘stimulation’ without overt heating
is advantageous in many circumstances (e.g. Watson 2000;
Watson 2006a; Kitchen and Dyson 2008). This is not to
denigrate the therapeutic benefits of heating as a therapeu-
tic tool, but rather to add a non-thermal aspect. Clearly,
all the modalities identified in this section could generate
significant heating if applied at sufficient levels. Their
application as described here is in the clinically non-
thermal mode.
In this section, ultrasound (traditional and LIPUS),
PSWT and laser therapies will constitute the main content.
Microcurrent therapy, as identified in the introductory
section, could fit in this section or in the electrical stimula-
tion section. For the purposes of this chapter, it has been
included in the electrical stimulation group. The emerging A
RF applications (see the ‘Thermal modalities’ section)
could also be included in this section, but until there is
sufficient new evidence their effects will be confined to the
thermal group.

Therapeutic ultrasound
Ultrasound therapy is one of the most commonly
employed electrophysical treatments in many countries.
Both mains-powered and battery-powered treatment units
are available and, additionally, it is reasonably common
to find ultrasound as one modality offered on multimodal
electrotherapy machines (Figure 19.19).
Ultrasound is a form of mechanical (vibration) energy,
and vibration at increasing frequencies is known as sound
energy. The normal human sound range is from 16 Hz to
something approaching 15–20,000 Hz. Beyond this upper
limit, the mechanical vibration is known as ultrasound.
The frequencies used in therapy are typically between 1.0 B
and 3.0 MHz (1 MHz = 1 million cycles per second) and
is clearly beyond the human sound detection range. Some
therapy devices offer application frequencies at other rates,
for example 1.5 MHz, 0.75 MHz and longwave ultrasound
devices that operate in the kilohertz range (e.g. 48 kHz
and 150 kHz). The effect of longwave ultrasound is beyond
the scope of this section, which will concentrate on ‘tradi-
tional’ (MHz) ultrasound.
Sound waves are longitudinal waves consisting of zones
of compression and rarefaction. Particles of a material,
when exposed to a sound wave will oscillate about a fixed
point. Clearly, any increase in the molecular vibration in
the tissue can result in heat generation and ultrasound
can be used to produce thermal changes in the tissues, C
though current usage in therapy does not focus on this
phenomenon (Nussbaum 1997; ter Haar 1999; Baker Figure 19.19  Examples of clinical ultrasound therapy
et al. 2001; Watson and Young 2008). In addition to machines: (a) mains-powered ultrasound machine (EMS
thermal changes, the vibration of the tissues has effects Physio); (b) mains/battery ultrasound machine (Chatanooga);
which are considered to be ‘non-thermal’ in nature, (c) multimodal device which includes ultrasound (Enraf).
although, as with other modalities, there must be a
thermal component – however small. As the ultrasound

435
 Tidy’s physiotherapy
wave passes through a material (the tissues), the energy
levels within the wave will diminish as energy is trans-
ferred to the material.
Ultrasound transmission through the tissues
All materials (tissues) will present impedance to the
passage of sound waves. The specific impedance of a tissue
will be determined by its density and elasticity. In order
for the optimal transmission of energy from one medium
to another, the impedance of the two media needs to be
as similar as possible. The greater the difference in imped-
ance at a boundary, the greater the reflection that will
occur and, therefore, the smaller the amount of energy that
will be transferred.
The difference in impedance is greatest for the steel/air
interface which is the first one that the ultrasound has to
overcome in order to reach the tissues. To minimise this
difference, a suitable coupling medium has to be utilised.
If even a small air gap exists between the transducer and
the skin, the proportion of ultrasound that will be reflected
approaches 99.998% which, in effect, means that there
will be no transmission.
The coupling media used in this context include water,
various oils, creams and gels. Ideally, the coupling medium
should be fluid so as to fill all available spaces, relatively
viscous so that it stays in place, have an impedance appro-
priate to the media it connects and should allow transmis-
sion of ultrasound with minimal absorption, attenuation
or disturbance. At the present time, gel-based media
appear to be preferable to oils and creams. Water is a good
media and can be used as an alternative but clearly it
fails to meet the above criteria in terms of its viscosity.
There is no realistic (clinical) difference between the gels
in common clinical use (Poltawski and Watson 2007).
Absorption and attenuation
The absorption of ultrasound energy follows an exponen-
tial pattern, i.e. more energy is absorbed in the superficial
tissues than in the deep tissues. In order for energy to have
an effect it must be absorbed. At some point this must be
considered in relation to the ultrasound dosages applied
to achieve certain effects. Because the absorption (penetra-
tion) is exponential, there is (in theory) no point at which
all the energy has been absorbed, but there is certainly a
point at which the ultrasound energy levels are not suffi-
cient to produce a therapeutic effect. As the ultrasound
beam penetrates further into the tissues, a greater propor-
tion of the energy will have been absorbed and therefore
there is less energy available to achieve therapeutic effects.
The half value depth is often quoted in relation to ultra-
sound and it represents the depth in the tissues at which
half the surface energy remains available.
As it is difficult, if not impossible, to know the thickness
of each specific tissue layer in an individual patient,
436
Table 19.1  Ultrasound intensity at various tissue
depths based on average half-value data
Depth (cm) 3 MHz 1 MHz
2 50%
4 25% 50%
6
8 25%
Increasing protein content
Blood, Fat, Nerve, Muscle, Skin, Tendon (Cartilage, Bone)
LOW US absorption HIGH
Best absorption therefore in tendon, ligament, fascia,
joint capsule and scar tissue
Figure 19.20  Ultrasound absorption in different tissues.
average half-value depths are employed for each frequency.
The ‘average’ half-value depths of commonly employed
ultrasound frequencies are: 3 MHz = 2.0 cm and 1 MHz
= 4.0 cm. Table 19.1 provides an estimate of the ultra-
sound energy remaining at various tissue depths relative
to the skin surface intensity.
To achieve a particular ultrasound intensity at depth,
account must be taken of the proportion of energy which
has been absorbed by the tissues in the more superficial
layers. The table gives an approximate reduction in energy
levels with typical tissues at two commonly used frequen-
cies. More detailed information and absorption tables are
available at www.electrotherapy.org and in Watson (2002).
As the penetration (or transmission) of ultrasound is
not the same in each tissue type, it is clear that some
tissues are capable of greater absorption of ultrasound
than others. Generally, the tissues with the higher protein
content will absorb ultrasound to a greater extent, thus
tissues with high water content and low protein content
absorb little of the ultrasound energy (e.g. blood and fat),
while those with a lower water content and a higher
protein content will absorb ultrasound far more efficiently.
It has been suggested that tissues can therefore be ranked
according to their tissue absorption (Figure 19.20).
Although cartilage and bone are at the upper end of this
scale, the problems associated with wave reflection mean
that the majority of ultrasound energy striking the surface
of either of these tissues is likely to be reflected. The
best absorbing tissues in terms of clinical practice are
those with high collagen content: ligament, tendon, fascia,
joint capsule and scar tissue (Frizzell and Dunn 1982;

Table 19.2  Pulse ratios and equivalent duty cycle
percentage for clinical ultrasound machines
Mode Pulse ratio Duty cycle
Continuous N/A 100%
Pulsed 1 : 1 50%
1 : 2 33%
1 : 3 25%
1 : 4 20%
1 : 9 10%
Nussbaum 1998; ter Haar 1999; Watson 2000; Watson
2008c; Watson and Young 2008).
The application of therapeutic ultrasound to tissues
with a low energy absorption capacity is likely to be less
effective than the application of the same energy to a more
highly absorbing material. Recent evidence of the inef-
fectiveness of such an intervention can be found in Wilkin
et al. (2004), while application in tissue that is a better
absorber will result in a more effective intervention (e.g.
Leung et al. 2004; Sparrow et al. 2005).
Pulsed ultrasound
Most machines offer the facility for pulsed ultrasound
output. Typical pulse formats are 1 : 1 and 1 : 4, although
others are available. In 1 : 1 mode, the machine offers an
output for 2 ms followed by 2 ms rest. In 1 : 4 mode, the
2 ms output is followed by an 8 ms rest period. The effects
of pulsed ultrasound are well documented (Watson 2008c;
Watson and Young 2008) and this type of output is prefer-
able, especially in the treatment of the more acute lesions.
The duty cycle (% of time during which the machine gives
an output) will be 50% for the 1 : 1 mode and 20% for the
1 : 4 mode. Table 19.2 illustrates the equivalent pulse ratios
and duty cycles (as a percentage).
Clinical uses of ultrasound therapy
One of the therapeutic effects for which ultrasound has
been used is in relation to tissue repair/healing. It is sug-
gested that the application of ultrasound to injured tissues
will, among other things, speed the rate of healing and
enhance the quality of the repair, which will be the focus
of this section.
The therapeutic effects of ultrasound are generally
divided into thermal and non-thermal groups.
Thermal effects and uses
In thermal mode, ultrasound will be most effective in
heating the dense collagenous tissues and will require a
Electrotherapy Chapter 19
relatively high intensity, preferably in continuous mode,
to achieve this effect.
Many articles have concentrated on the thermal effec-
tiveness of ultrasound and, much as it can be used effec-
tively in this way when an appropriate dose is selected
(continuous mode >0.5 W cm−2), the focus of this chapter
will be on the non-thermal effects. Both Nussbaum (1998)
and ter Haar (1999) have provided some useful review
material with regard to the thermal effects of ultrasound.
Comparative studies on the thermal effects of ultrasound
have been reported by several authors (e.g. Draper et al.
1993; Draper and Ricard 1995; Draper et al. 1995; Meakins
and Watson 2006) with some interesting, and potentially
useful, results.
It is too simplistic to assume that a particular treatment
application will either have thermal or non-thermal
effects. It is almost inevitable that both will occur, but,
furthermore, it is reasonable to argue that the dominant
effect will be influenced by treatment parameters, espe-
cially the mode of application, i.e. pulsed or continuous.
Baker et al. (2001) have argued the scientific basis for this
issue coherently.
Non-thermal effects and uses
The non-thermal effects of ultrasound are now attributed
primarily to a combination of cavitation and acoustic
streaming (Williams et al. 1987; ter Haar 1999; Baker et al.
2001; Watson 2008c). There appears to be little by way of
convincing evidence to support the notion of micromas-
sage, although it does sound rather appealing. Details of
these primary physical effects of ultrasound are detailed in
appropriate texts and papers (Robertson et al. 2006;
Watson and Young 2008).
The result of the combined effects of stable cavitation
and acoustic streaming is that the cell membrane becomes
‘excited’ (up-regulates), thus increasing the activity levels
of the whole cell. The ultrasound energy acts as a trigger
for this process, but it is the increased cellular activity
which is in effect responsible for the therapeutic benefits
of the modality (Figure 19.21) (Dinno 1989; Watson
2000, 2008c; Leung et al. 2004; Watson and Young 2008).
Ultrasound application in relation
to tissue repair
The process of tissue repair is a complex series of cascaded,
chemically-mediated events that lead to the production of
scar tissue that constitutes an effective material to restore
the continuity of the damaged tissue. The process is more
complex than will be described here and there are numer-
ous review articles, including Watson (2003, 2006a).
Inflammation
During the inflammatory phase, ultrasound has a stimu-
lating effect on the mast cells, platelets, white cells with
437
 Tidy’s physiotherapy

Stable
cavitation
Altered cell Altered protein synthesis
membrane potential Altered release of cell contents
Altered local blood flow
Mechanical disturbance Acoustic Altered vascular permeability
by means of pressure wave streaming Angiogenesis
Change in Altered collagen
cell membrane content and alignment
(Micro- transport mechanisms
massage)

Physical Physiological Therapeutic

Figure 19.21  Proposed mechanisims of ultrasound action.

phagocytic roles and the macrophages (Maxwell 1992; Proliferation

Nussbaum 1997; ter Haar 1999). For example, the applica-
During the proliferative phase, ultrasound also has a stim-
tion of ultrasound induces the degranulation of mast cells,
ulative effect (cellular up-regulation), though the primary
causing the release of arachidonic acid (which itself is a
active targets are now the fibroblasts, endothelial cells and
precursor for the synthesis of prostaglandins and leukot-
myofibroblasts (Dyson and Smalley 1983; Mortimer and
riene), which act as inflammatory mediators (Mortimer
Dyson 1988; Young and Dyson 1990a, 1990b; Maxwell
and Dyson 1988; Nussbaum 1997; Leung et al. 2004). By
1992; Nussbaum 1997, 1998; Ramirez et al. 1997). These
increasing the activity of these cells, the overall influence
are all cells that are normally active during scar produc-
of therapeutic ultrasound is certainly pro-inflammatory
tion, and ultrasound is therefore pro-proliferative in the
rather than anti-inflammatory. The benefit of this mode of
same way that it is pro-inflammatory – it does not change
action is not to ‘increase’ the inflammatory response as
the normal proliferative phase, but maximises its effi-
such (though if applied with too great an intensity at this
ciency – producing the required scar tissue in an optimal
stage, it is a possible outcome (Ciccone et al. 1991) ), but
fashion. Harvey et al. (1975) demonstrated that low dose,
rather to act as an ‘inflammatory optimiser’. The inflam-
pulsed ultrasound increases protein synthesis, and several
matory response is essential to the effective repair of tissue
research groups have demonstrated enhanced fibroplasia
and the more efficiently the process can complete, the
and collagen synthesis (Enwemeka 1989; Turner et al.
more effectively the tissue can progress to the next phase
1989; Enwemeka et al. 1990; Huys et al. 1993; Ramirez
(proliferation). Ultrasound is effective at promoting the
et al. 1997). Recent work has identified the critical role of
normality of the inflammatory events and, as such, has a
numerous growth factors in relation to tissue repair and
therapeutic value in promoting the overall repair events
some accumulating evidence has identified that therapeu-
(ter Haar 1999). A further benefit is that the inflammatory,
tic ultrasound has a positive role to play in this context
chemically-mediated events are associated with stimula-
(e.g. Reher et al. 2002).
tion of the proliferative phase and, hence, the promotion
of the inflammatory phase also acts as a promoter of
repair. Remodelling
Employed at an appropriate treatment dose, with During the remodelling phase of repair, the somewhat
optimal treatment parameters (intensity, pulsing and generic scar that is produced in the initial stages is refined
time), the benefit of ultrasound is to make as efficient as such that it adopts functional characteristics of the tissue
possible the earliest repair phase and, thus, have a promo- that it is repairing. This is achieved by a number of pro-
tional effect on the whole healing cascade. For tissues in cesses, but is mainly related to the orientation of the col-
which there is an inflammatory reaction, but in which lagen fibres in the developing scar and also to the change
there is no ‘repair’ to be achieved, the benefit of ultrasound in collagen type, from predominantly type III collagen to
is to promote the normal resolution of the inflammatory a more dominant type I collagen (Watson 2006b).
events, and hence resolve the ‘problem’ This will be most The application of therapeutic ultrasound can influence
effectively achieved in the tissues that preferentially absorb the remodelling of the scar tissue in that it appears to be
ultrasound, i.e. the dense collagenous tissues (Watson capable of enhancing the appropriate orientation of the
2006a, 2008c). newly formed collagen fibres and also to the collagen

438

profile change from mainly type III to a more dominant
type I construction, thus increasing tensile strength and
enhancing scar mobility (Nussbaum 1998; Wang 1998).
Ultrasound applied to tissues enhances the functional
capacity of the scar tissues (Huys et al. 1993; Nussbaum
1998; Yeung et al. 2006). The role of ultrasound in this
phase may also have the capacity to influence collagen
fibre orientation as demonstrated in an elegant study by
Byl et al. (1996).
The application of ultrasound during the inflammatory,
proliferative and repair phases is not of value because it
changes the normal sequence of events, but because it has
the capacity to stimulate or enhance these normal events
and thus increase the efficiency of the repair phases (ter
Haar 1999; Watson 2006a, 2008c). It would appear that
if a tissue is repairing in a compromised or inhibited
fashion, the application of therapeutic ultrasound at an
appropriate dose will enhance this activity. If the tissue is
healing ‘normally’, the application will optimise the
process and thus enable the tissue to reach its endpoint
faster than would otherwise be the case. The effective
application of ultrasound to achieve these aims is
dose-dependent.
Treatment doses
It appears to be important to make an accurate dose selec-
tion when applying therapeutic ultrasound. There are
numerous research articles which have demonstrated no
therapeutic/clinical value when using the modality, and
part of the reason for this would appear to be that there
is a dose-dependency in terms of therapeutic outcome
(reviewed in Watson 2010) though others have argued
against this proposition (Robertson 2002).
The detail of making dose selections is beyond
the remit of this chapter. Essentially, it involves the varia-
tion of frequency, pulsing ratio (duty cycle), intensity
and time. Details of calculation methods have been
published (e.g. Watson 2002) and are also available at
various web resources and manufacturers’ sites (e.g.
www.electrotherapy.org).
Low intensity pulsed ultrasound
(LIPUS) and fracture healing
There has recently been a strong range of research articles
that have identified the potential for low intensity ultra-
sound to promote tissue repair, most strongly evidenced
in relation to fractures, including both ‘normal’, delayed/
non-union and post-surgery clinical scenarios.
While it is beyond the remit of this chapter to present
a full analysis of this increasingly popular treatment, the
essentials will be covered and some key references pre-
sented. It is suggested that while this may not yet consti-
tute a ‘normal’ physiotherapy treatment, it is anticipated
that it is likely to become so within the near future.
Electrotherapy Chapter 19
Figure 19.22  Example of LIPUS device. Exogen (Smith and
Nephew).
Numerous recent articles have identified the benefits of
using therapeutic ultrasound for both normally healing
(fresh) fractures and delayed union or non-union situa-
tions. A systematic review and meta-analysis (Busse et al.
2002) has carefully considered the evidence in respect to
the effect of LIPUS on the time to fracture healing. They
conclude that the evidence from randomised trials where
the data could be pooled (3 studies, 158 fractures)
that the time to fracture healing was significantly reduced
in the ultrasound-treated groups than in the control
groups and the mean difference in healing time was 64
days. The systematic review (Griffin et al. 2008) evaluating
LIPUS for fresh fractures considers seven randomised con-
trolled trials and two meta-analyses, suggesting that this
body of evidence is supportive. Warden et al. (2000) pub-
lished a review article and concluded from animal and
human studies that the use of LIPUS could accelerate the
rate of fracture repair by a factor of up to 1.6.
The units utilised for this work deliver a very low inten-
sity (0.03 W cm−2 or 30 mW/cm−2) at 1.5 MHz pulsed at
a ratio of 1 : 4 at 1 kHz, applied for 20 minutes daily.
An examples of a currently available specialist LIPUS
device is illustrated in Figure 19.22. The intensity of this
application is considerably lower than the lowest intensity
which is deliverable by the majority of current therapy
ultrasound machines (normally 0.1 W cm−2) and although
Warden et al. (Warden et al. 1999) have tried to replicate
this using standard therapy devices, it has only been evalu-
ated using an animal model to date and human trials with
physiotherapy ultrasound machines have yet to be reported
in the published literature. The key issue, in addition
to the very low intensity, is that these specific devices
have a particularly low beam uniformity (BNR) and thus
are considered to be safe to apply with a stationary treat-
ment head, unlike conventional physiotherapy ultrasound
machines. This could be an important factor given the
20 minutes treatment duration on a daily basis, with a
439
 Tidy’s physiotherapy
static treatment applicator and, most commonly, with the
patient using the device at home rather than attending
for therapy.
Heckman et al. (1994) demonstrated a 38% reduction
in the healing time for tibial fractures using a LIPUS
device, while Kristiansen et al. (1997) demonstrated a
30% acceleration in healing for fractures of the radius.
Jensen (1998) identifies the beneficial effects of ultra-
sound in the treatment (as opposed to the diagnosis) of
stress fractures with an overall success rate of 96%. Mayr
et al. (2000) report a series of outcomes when using LIPUS
for patients with delayed unions (n = 951) and non-
unions (n = 366). The overall success rate for the delayed
unions was 91% for the delayed unions and 86% for the
non-unions.
The authors undertook an interesting stratified analysis
of their patients, and identified that those who were using
non-steroidal anti-inflammatory drugs (NSAIDs), calcium
channel-blockers or steroids had a less favourable outcome
– a finding that could be considered to be consistent with
several research publications that have tried to identify the
mechanism by which the ultrasound could bring about
fracture healing acceleration and other wider research con-
cerning the adverse influence of NSAIDs on tissue repair
(e.g. Evans and Butcher 2004; Tsai et al. 2004).
Of the reviews specific to LIPUS treatment of delayed
union and non-union, Romano et al. (2009) identify a
success rate for LIPUS of between 70% and 93%, which is
impressive when compared with the ‘typical’ rates after
surgery and bone graft. Rutten et al. (2007) reviewed tibial
non-unions treated in the Netherlands with LIPUS and
provide evidence for a 73% healing rate, significantly
better than that achieved in non-LIPUS groups. Claes and
Willie (2007) review the reviews and, in addition to an
evaluation of the clinical effectiveness and uses, also try to
make some sense of the wide range of proposed mecha-
nisms by which this intervention achieves its effects.
Further reviews are offered by Hadjiargyrou et al. (1998),
Tsunoda (2003), Malizos et al. (2006), and Pounder and
Harrison (2008), who identify a success rate of some 80%
in Japan.
The use of such low doses has been shown to result in
non-significant increases in tissue temperature. Using
higher ultrasound doses could have an adverse effect on
the fracture healing process (Chang et al. 2002) and LIPUS
is considered to be effective and safe for this patient group.
A review by Jingushi et al. (2007) usefully includes a com-
mentary on the potential mechanisms for this effect, while
Della Rocca (2009) also reviews the literature in this field,
including the potential mechanisms of effect, though
much of the work considered relates to animal and labora-
tory experimentation. The mechanisms by which thera-
peutic ultrasound can be effective for fracture repair
includes nitric oxide pathways and prostaglandin (PGE2)
(Warden et al. 2001; Reher et al. 2002). This too would be
consistent with other proposed mechanisms of ultrasound
440
action (ter Haar 1999) and the relationship between the
use of NSAIDs and tissue repair following injury.
Tis et al. (2002) and Sakurakichi et al. (2004) have
evaluated the use of ultrasound as a component of treat-
ment (in an animal model) during distraction osteogen-
esis; both demonstrated significant benefits. Cook et al.
(2001) have demonstrated similar benefits following
spinal fusion surgery and Tanzer et al. (2001) have shown
that the use of ultrasound in combination with porous
intramedullary implants is also beneficial.
LIPUS, therefore, is a well-evidenced and effective
therapy intervention for fresh fractures, delayed unions
and non-unions, and as an adjunctive treatment post-
surgery. The treatment parameters are well defined and it
appears to be most commonly employed as a home-based
therapy on the basis that this is the most cost effective
way to deliver the treatment. It is anticipated that thera-
pists will become more involved in the organisation,
delivery and monitoring of this treatment package as
it becomes more widespread. It remains possible that
future generations of ultrasound machines in clinics may
have the facility to deliver this effective treatment dose
so that it can be used as a clinic option if home-based
therapy is impractical or unrealistic as an option. There
have been suggestions, but little evidence to date, that
the LIPUS approach may also be beneficial for muscu-
loskeletal and soft tissue lesions. While there is anecdotal
evidence, there is little as yet in the published work to
provide unequivocal support, although this field may
develop as swiftly as fracture research has over the last
10–15 years.
Pulsed shortwave therapy (PSWT)
PSWT is a widely used modality in the UK (Al Mandeel
and Watson 2006), though it is often called pulsed elec-
tromagnetic energy (PEME) which is less than fully appro-
priate in that many modalities come under the heading of
PEME – PSWT being only one of them – and the use of
the term is best avoided. The older term ‘pulsed shortwave
diathermy’ is not really appropriate either in that the
modality is not primarily employed as a diathermy (liter-
ally ‘through heating’).
PSWT employs the same operating frequency as tradi-
tional SWD, i.e. 27.12 MHz. The output from the machine
is pulsed such that the ‘on’ time is considerably shorter
than the ‘off’ time, thus the mean power delivered to the
patient is relatively low, even though the peak power (i.e.
during the on pulses) can be quite high (typically around
150–200 W peak power with modern machines – exam-
ples of which are illustrated in Figure 19.23.
The control offered by the machine will enable the user
to vary (a) the mean power delivered to the patient
and (b) the pulsing parameters governing the mode
of delivery of the energy. It would seem from current
research that the mean power is probably the most
 Electrotherapy Chapter 19

important parameter (e.g. Hill et al. 2002; Al Mandeel and

Watson 2008).
When using pulsed shortwave in the clinical environ-
ment, there are two ‘modes’ of application, and the infor-
mation in this section relates to application using the
‘monode’ or ‘drum’ electrode rather than the capacitor
plate delivery system which lacks sufficient supportive
evidence.

Main machine parameters

Pulse repetition rate (Hz or pps)
The pulse repetition rate controls the number of pulses of
shortwave energy that are delivered to the patient in a
second. The units are often denoted in Hertz (Hz),
although pulses per second (pps) is probably a more
appropriate term. Most, if not all, machines offer a pre-set
range of pulse repetition options with widely varying
options. There is no evidence that the actual value of the
pulse rate is critical, but the ability to deliver greater or
A
fewer pulses per second does enable the user to influence
the mean power (see below).

Pulse duration (width)

The pulse duration (often called the pulse width) refers to
the duration, in microseconds, of each individual pulse of
shortwave energy. Most, but not all machines, allow the
therapist to adjust the pulse duration using a range of
pre-set options. There is no evidence that the actual dura-
tion is a critical measure – it is simply a means of influenc-
ing mean power delivery.

Power output of the machine

The combination of having the facility to determine both
the repetition rate of the pulses and the duration of each
pulse enables the user to influence the mean power deliv-
ered to the patient.
The peak power (which can sometimes, but not always,
be controlled by the operator) is typically around 150–
200 W in modern machines. This is the ‘strength’ of the
shortwave whilst the pulse is on, i.e. energy is delivered to
the patient. The mean power takes account of the fact that
there are on and off phases – the energy delivery is intermit-
tent – and thereby describes the average power output
rather than the power output at any one moment in time
(which might be maximum or zero).
The relationship between the pulse parameters and the
power levels are illustrated in Figure 19.24.

Mean power
B
The applied mean power appears to be the critical dose
parameter in the clinical environment. Each different type
of pulsed shortwave machine will have a ‘mean power’
Figure 19.23  Examples of pulsed shortwave therapy devices:
table associated with it, and it is from this table that the
(a) Megapulse system (EMS Physio); (b) Curapuls system
(Enraf).
therapist is able to establish the settings required to deliver

441
 Tidy’s physiotherapy
Peak power
Mean power
Pulse
width
(duration) Pulse
repetition rate
Figure 19.24  The relationship between pulse parameters
and power levels with pulsed shortwave therapy.
a mean power of XX Watts. If, for example, it is intended
to deliver a mean power of 5 W with a particular machine,
the therapist should consult the table specific for that
machine to determine exactly which combination of pulse
repetition rate and pulse duration will provide the required
mean power. It is important to note that these tables are
not transferable between machines. The settings made on
machine A and machine B to achieve the same mean
power may well be different. Getting the mean power
levels ‘correct’ appears to be more important than any
other individual parameter.
Tissue heating
With respect to the effects of pulsed shortwave, there is an
element of tissue heating which occurs during the ‘on’
pulse, but this is dissipated during the prolonged ‘off’
phase and, therefore, it is possible to give treatment with
no net increase in tissue temperature. In Figure 19.25, part
(a) demonstrates no accumulation of either thermal or
non-thermal effects. In part (b), the pulses are sufficiently
close to generate an accumulative non-thermal effect and
in part (c) there is an accumulation of both thermal and
non-thermal effects. The settings applied on the machine
will determine which of these is achieved in a particular
treatment. The ‘non-thermal’ effects of the modality are
generally thought to be of greater significance. They appear
to accumulate during the treatment time and have a sig-
nificant effect after a latent period, possibly in the order
of 6–8 hours. It is suggested (Hayne 1984) that the energy
levels required to produce such an effect in humans
are low.
Research has been conducted over several years relating
to the thermal nature of PSWT. It was unclear just what
power levels were required to bring about real tissue
heating and, in fact, there has been some opinion that
PSWT is a non-thermal modality. Research has demon-
strated (e.g. Bricknell and Watson 1995) that PSWT does
have a thermal component and that real tissue heating
442
can occur under different treatment settings. This is
im­portant in that if the modality is to be applied in cir-
cumstances where the heating would be inappropriate or
contraindicated, it is essential to know the power/energy
levels where the thermal effects begin. This research
shows that a measurable heating effect can be demon-
strated at power levels over 5 Watts, though on average, it
will become apparent at some 11 Watts mean power. More
recent work (Seiger and Draper 2006) suggests that it may
still be safe to apply higher mean power levels than previ-
ously thought, even with metal in the tissues. A clinical
trial using PSWT at 48 Watts mean power in the tissues
resulted in clinical benefit and no adverse outcomes, even
when there was metal in the tissues.
If a ‘non-thermal’ treatment is the intended outcome
of the treatment, it is essential that the mean power
applied remains below a level that is likely to induce sig-
nificant heating effects, and at present, this is taken as
being at 5 Watts mean power. If a thermal effect is an
intentional outcome of the intervention, then it may be
perfectly appropriate to deliver power levels in excess of
5 Watts, but, if doing so, the therapist must ensure that
the precautions are taken as for any other thermal
intervention.
Effects of PSWT
Effects of PSWT can be divided into two basic types – those
of the electric field and those of the magnetic field. There
appears to be almost no literature/research concerning the
effects of pulsing the electric field (using condenser plate
electrodes) and all the research identified here is con-
cerned with the therapeutic effects of the magnetic field
(monode-type electrode).
The primary effects of the pulsed magnetic field appear
to be at the cell membrane level and are concerned
with the transport of ions across the membrane. Some
interesting publications have strongly supported the
‘non-thermal’ effects at cell membrane level (Cleary 1996;
Luben 1996).
Normal cell membranes exhibit a potential difference
owing to the relative concentration differences of various
ions on either side of the membrane (reviewed in Charman
1990). It is argued that the application of energy that is
absorbed at the cell membrane level results in cellular
‘up-regulation’ and thereby increases levels of cellular
activity – this is not a change in role, but effectively an
increase in work rate (Al Mandeel and Watson 2008).
Cells involved in the inflammatory process demon-
strate a reduced cell membrane potential and conse-
quently, the cell function is disturbed. The altered
potential affects ion transport across the membrane, and
the resulting ionic imbalance alters cellular osmotic pres-
sures. The application of PSWT to cells affected in this
way is claimed to restore the cell membrane potential to
their ‘normal’ values and also restores normal membrane
 Electrotherapy Chapter 19

Shortwave
pulses

Thermal
effect

Non-thermal
effect

Shortwave
pulses

Thermal
effect

Non-thermal
effect

Shortwave
pulses

Thermal
effect

Non-thermal
effect

Figure 19.25  (a–c) Effect of varying the pulse parameters on the accumulated heat generated in the tissues. (a) Pulses at
sufficient ‘distance’ – no accumulative effect. (b) Pulses closer together – accumulating non-thermal effect, no thermal
accumulation. (c) Pulses closer still – accumulation of thermal and non-thermal effects.

transport and ionic balance. The mechanism by which
this effect is brought about has not yet been established,
but the two theories suggest that this is either a direct
ionic transport mechanism or an activation of various
pumps (sodium/potassium) by the pulsed energy. Evi-
dence (Luben 1996) supports the contention that the
energy is absorbed in the membrane and that via a mech-
anism of signal transduction, stimulates or enhances
intracellular effects.
There appears to be a strong similarity in the mecha-
nism of effect of ultrasound, laser and pulsed shortwave
– all three modalities appear to have their primary effect
at cell membrane level, with the resulting ‘up-regulation’
of cellular behaviour being the key to the therapeutic
effects.
PSWT: Clinical effects
The clinical effects of PSWT are related primarily to the
inflammatory and repair phases in musculoskeletal/soft
tissues. Goldin et al. (1981) lists the effects of the modality
(following research in soft tissue repair following skin
graft application). Other articles have similarly identified
the list of effects, which are most easily reviewed in the
standard electrotherapy texts (Robertson et al. 2006;
Watson 2006a, 2008c).

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 Tidy’s physiotherapy

Suggested treatment doses

In light of current research, it is suggested that the
minimum energy required to achieve a therapeutic effect
should be utilised. Specific detailed research (clinical and
laboratory) is essential for further validation of the treat-
ment which is currently criticised for being unfounded.
There is also a strong argument that the concentration of
electromagnetic energy is likely to be critical, and it may
be in the near future that PSWT doses are described more
in terms of mean power concentration (W cm−2) rather
than just Watts. This would be in keeping with ultrasound
and laser therapies.
A
The general guide below is based on both clinical and
research evidence wherever possible. Further details can be
found in specific research articles, standard texts and on
the www.electrotherapy.org website.

Acute conditions
Apply a mean power of less than 3 Watts. The more acute
the lesion presentation, the lower the delivered mean
power (i.e. 3 Watts is maximal for this group). Using
shorter duration (narrower) pulses and higher repetition
rate may be beneficial and the typical treatment time is
between 10 and 15 minutes.

Sub-acute conditions
Apply a mean power of between 2 and 5 Watts and as the
condition becomes less acute, longer duration (wider) B
pulses appear to be preferable. Treatment time is typically
in the region of 15 minutes.

Chronic conditions
Application of a mean power greater than 5 Watts is
usually required in order to achieve a reasonable tissue
response. As noted previously, when such mean powers
are employed, it is important to remember that the
‘thermal’ effect of pulsed shortwave becomes apparent at
power levels greater than 5 Watts, and therefore appropri-
ate thermal precautions need to be taken. Pulses of longer
duration are probably of benefit if there is a choice, and
treatment times are typically between 15 and 20 minutes.
Some therapists ‘worry’ about using ‘high’ doses with
PSWT, but even the higher doses on modern machines C
deliver considerably less energy than those used in the past
without ill effect. Much as low doses appear to be very Figure 19.26  Typical laser therapy devices: (a) THOR;
effective, especially for the more acute conditions, doses (b) EMS Physio; (c) Gymna.
up to 48 Watts mean power are safe, evidenced and clini-
cally effective in some (chronic) circumstances. amplifier – it provides enhancement of particular proper-
ties of light energy. Examples of commonly encountered
Laser therapy/low level laser laser therapy devices are illustrated in Figure 19.26.
Laser light will behave according to the basic laws of
therapy/low intensity laser therapy
light in that it travels in straight lines at a constant velocity
The term ‘laser’ is an acronym for the light amplification in space. It can be transmitted, reflected, refracted and
by stimulated emission of radiation. In simple, yet realis- absorbed. It can be placed within the electromagnetic
tic, terms, the laser can be considered to be a form of light spectrum according to its wavelength/frequency, which

444
 Electrotherapy Chapter 19

Cosmic Gamma X-rays Ultraviolet Visible Infrared Micro- Radio

rays rays light light radiation waves waves

380nm 770nm

Ultraviolet
V I B G Y O R Infrared
Figure 19.27  Light energy as a part of the electromagnetic spectrum.

will vary according to the particular generator under con-

sideration (Figure 19.27).
There are several aspects of laser light which are deemed
to be special and are often referred to in the literature
(Figure 19.28). These include monochromacity, coherence
and polarisation. There remains some doubt as to exactly White light
Multiple wavelengths
how essential these particular aspects of laser light are in
Non-coherent
relation to the therapeutic application of this energy form. A
Monochromacity is probably the most important factor,
as many of the therapeutic effects have been noted in
various trials with light which is non-coherent. Addition-
ally, it is thought that the polarisation is soon lost within
the tissues and may therefore be less important than was
thought at first.
Therapy lasers have several common characteristics
which are summarised below.
Laser light
Terms Single wavelength (monochromatic)
Coherent
Therapy lasers tend to fall into a particular category of laser B
light known as 3A or 3B. More recently, the terms low level
laser therapy (LLLT) and low intensity laser therapy (LILT)
have been adopted. Ohshiro and Calderhead (1988)
suggest that LLLT involves treatment with a dose that
causes no detectable temperature rise in the treated tissues
and no macroscopically visible change in tissue structure
– essentially, the energy can cause an increase in tempera-
ture and a change in tissue structure, but that is not the
intention with therapy laser which is applied at levels
below that needed to achieve these more overt effects
(compared with surgical laser). LED light
Monochromatic
Non-coherent
Parameters C
Most LLLT apparatus generates light in the red visible and Figure 19.28  Characteristics of various light forms:
near infrared bands of the electromagnetic spectrum (a) ‘normal’ white light; (b) true laser light; (c) LED-type  
(Figure 19.27), with typical wavelengths of 600–1000 nm. laser light.

445
 Tidy’s physiotherapy
A nucleic acids. The longer infrared radiation wavelengths
B
Figure 19.29  Laser therapy applicators: (a) cluster probes
(Thor); (b) single and cluster probes (EMS Physio).
The mean power of such devices is generally low (1–
100 mW), though the peak power may be much higher
than this.
The treatment device may be a single emitter or a cluster
of several emitters (Figure 19.29), though it is common
for most emitters in a cluster to be non-laser-type devices.
The beam from single probes is usually narrow (Ø1 mm
to 6 or 7 mm) at the source. A cluster probe will usually
incorporate both higher and lower power emitters of dif-
ferent wavelengths.
The output may be continuous or pulsed, with narrow
pulse widths (in the nano- or microsecond ranges) and a
wide variety of pulse repetition rates from 2 Hz up to
several thousand Hz. It is difficult to identify the evidence
for the use of pulsing from the research literature, though
it would appear to be a general trend (anecdotal) that the
lower pulsing rates are more effective in the acute condi-
tions while higher pulse rates work better in more chronic
conditions.
Many texts make reference to the types of generators
according to the gas contained within the tube, but in
446
therapy applications most modern apparatus utilise laser
diodes, most commonly made of gallium aluminium arse-
nide (GaAlAs) in which the ratio of the constituents deter-
mines the wavelength of the output or alternatively, laser
light emitting diodes (LEDs) of various kinds.
Light absorption in the tissues
As with any form of energy used in electrotherapy, the
energy must be absorbed by the tissues in order to have
some effect. The absorption of light energy within the
tissues is a complex issue, but, generally, the shorter wave-
lengths (ultraviolet and shorter visible) are primarily
absorbed in the epidermis by the pigments, amino and
(>1300 nm) appear to be rapidly absorbed by water and
therefore have limited penetration into the tissues. The
bands between (i.e. 600–1000 nm) are capable of penetra-
tion beyond the superficial epidermis and are, in part at
least, available for absorption by other biological tissues.
When applied to the body tissues, LLLT delivers energy
at a level sufficient to disturb local electron orbits and
result in the generation of heat, initiate chemical change,
disrupt molecular bonds and produce free radicals. These
are considered to be the primary mechanisms by which
LLLT achieves its physiological, and therefore therapeutic,
effects and the primary target is effectively the cell mem-
brane (see below).
Although much of the applied laser light is absorbed in
the superficial tissues, it is proposed that deeper or more
distant effects can be achieved, probably as a secondary
consequence via some chemical mediator or second mes-
senger systems, though there is limited evidence to fully
support this contention.
The actual penetration of LLLT at common wavelengths
is a widely debated point and it is common to find widely
varying values cited in the literature. It is often claimed
that because laser light is monochromatic, polarised and
coherent it is capable of greater penetration than ‘normal’
(or non-coherent) light. This should give penetration
depths of 3–7 mm for visible red light and some 30–
40 mm (at best) for infrared radiation laser light. The fact
that the polarisation appears to be lost in the tissues, as
is much, if not all, of the coherence, will result in a shal-
lower penetration. King (1990) cites a penetration depth
for 630 nm light to be 1–2 mm, while at 800–900 nm
penetration depths of 2–4 mm are expected. (Penetration
depth in this context refers to the depth of the tissues to
which 37% of the light at the surface is able to penetrate.)
A very small percentage of the light energy available at the
surface will be available at 10–15 mm into the tissues.
Laser–tissue interaction
Photobioactivation is a commonly used phrase in connec-
tion with LILT. It means the stimulation of various

biological events using light energy but without significant
temperature changes. Much, if not all, of the cited work
on therapeutic lasers consider these photobioactivation
effects. Some authors have proposed that there are other
terms which are preferable, including photobiostimulation
and photobiomodulation. It provides for a great semantic
argument, but assume at this point that these terms are
generally interchangeable.
Many of the early ideas of photobioactivation were pro-
posed by Karu who reported and demonstrated several key
factors. She notes in her 1987 article that some biomole-
cules change their activity in response to irradiation with
low intensity visible light, but that these molecules do not
appear to absorb the light directly. The cell membrane
appears to be the primary absorber of the energy which
then generates intracellular effects by means of a second
messenger/cascade-type response. The magnitude of the
photoresponse was deemed to be determined at least in
part by the state of the cells/tissues prior to irradiation,
summarised in a beautifully simple statement that ‘starv-
ing cells are more photosensitive than well fed ones’. The
laser light irradiation of the tissues is seen then as a trigger
for the alteration of cell metabolic processes via a process
of photosignal transduction. The often cited Arndt-Schults
Law supports this proposal.
The following list of physiological and cellular level
effects is compiled from several reviews and research
papers (e.g. Baxter 2002, 2008; Tuner and Hode 2004) and
does not claim to be complete or guaranteed for the in vivo
situation. It does, however, illustrate the range and scope
of photobioactivation effects:
• altered cell proliferation;
• altered cell motility;
• activation of phagocytes;
• stimulation of immune responses;
• increased cellular metabolism;
• stimulation of macrophages;
• stimulation of mast cell degranulation;
• activation and proliferation of fibroblasts;
• alteration of cell membrane potentials;
• stimulation of angiogenesis;
• alteration of action potentials;
• altered prostaglandin production;
• altered endogenous opioid production.
Treatment doses
Most research groups and many manufacturers recom-
mend that the dose delivered to a patient during a treat-
ment session should be based on the energy density rather
than the power or other measure of dose. Energy density
is measured in units of Joules per square centimetre
(J/cm2). One of the most significant inhibitors to the more
widespread adoption of laser therapy in the clinical envi-
ronment relates to the difficulty in getting these ‘effective’
laser doses to work on a particular machine. Few devices
Electrotherapy Chapter 19
enable the practitioner to set the dose in J/cm2. Some will
provide Joules, some Watts and some Watts/cm−2. It is
currently argued that Joules (i.e. energy) may, in fact, be
the most critical parameter rather than energy density. The
debate is not yet resolved. Energy density will be used here,
mainly because the published research almost exclusively
cites it and, therefore, it may be of more use when it comes
to trying to replicate an evidence-based treatment dose.
Some machines offer ‘on board’ calculations of this
dose, while other machines require the operator to make
some calculations based on known machine parameters:
• output power (Watts);
• irradiation area (cm2);
• time (seconds);
• if pulsed – pulse width, frequency and power
settings.
Total amount of energy (J)
Energy density (J/cm2 ) =
Irradiation area (cm2 )
Total energy (J) = Average power ( Watts) × time (sec)
Average power ( Watts) (pulsed output only )
= Peak power ( W) × frequency (Hz) ×
pulse duration (sec)
There are various alternative methods for calculating
these doses, but those cited above offer a reasonably
simple method should one be needed.
Most authorities suggest that the energy density per
treatment session should generally fall in the range of
0.1–12.0 J/cm2 although there are some recommenda-
tions which go up to 30 J/cm2. Again, as a generality, lower
doses should be applied to the more acute lesions which
would appear to be more energy sensitive.
Clinical applications
Recent research, both laboratory-based and clinical trials,
is found to concentrate on a few key areas. Most dominant
among these are wound healing, inflammatory arthropa-
thies, soft tissue injury and the relief of pain (which
includes laser acupuncture). There is supportive research
for the clinical use of LLLT in these and other circum-
stances, but, as with many treatment modalities, the evi-
dence remains somewhat controversial at the present time.
Open wounds
There is a growing body of evidence in this context, with
some mixed results but, on the whole, they are positive
outcome trials. There are useful sections in Baxter (1994,
2008), and Tuner and Hode (2004). A general summary
might conclude that a treatment programme could be:
treat to the floor of the ulcer/pressure sore/wound, prefer-
ably using a cluster probe to cover the area, typically up
to 2 J/cm2. Also treat the margin/periphery normally using
447
 Tidy’s physiotherapy
a single probe with a dose typically up to 4 J/cm2. Care
will need to be taken to ensure infection control policies
are maintained, especially with laser treatment applicators
being placed in contact with wounds.
Inflammatory arthropathies
There have been several trials involving the use of LILT and
various inflammatory problems in joints. As with the
wound work, there are mixed results, but the general trend
appears to be supportive. The Ottawa Panel (Ottawa-Panel
2004) review was supportive of laser therapy in rheuma-
toid arthritis.
Soft tissue injury
There is a fairly widespread use of LILT in a variety of soft
tissue treatments. Some results are excellent and others
poor. It is possible that the weak results relate to incorrect
doses or possibly considering the use of laser therapy
for injuries that are simply beyond the reach of the energy
delivered. Tuner and Hode (2004) describe multiple
examples of effective (and less effective) soft tissue treat-
ments with LILT and identify some of the key research in
this area. Further material is also included in the Baxter
(2008) review.
Pain
It has been broadly assumed (until recently) that the effect
of laser therapy with regards to pain relief was primarily a
secondary effect of dealing with the inflammatory state.
While this may well be true (to some extent at least), there
is growing evidence that laser therapy can have a more
direct effect of nerve conduction characteristics and hence
may result in reduced pain as a more direct effect of the
therapy (e.g. Vinck et al. 2005).
The therapeutic use of lasers has increased slowly in the
general practice of therapy, though there are specialist
areas where it is strongly advocated, for example wound
healing. One of the key issues limiting the more wide-
spread uptake of the modality is the apparent difficulty in
deciding on an effective clinical dose and then setting the
machine to deliver such a dose. It is hoped that with
increases in technology, this will become an easier task
and, thus, the clinical application of laser therapy is likely
to increase in the short- to medium-term future.
The last of the ‘non-thermal’ modalities that will be
briefly included is shockwave therapy, which is emerging
in both practice and research terms. It is difficult to
know where it should ‘fit’ in the categorisation of electro-
physical agents. It employs a mechanical energy (like ultra-
sound), is applied at high energy (like the thermal
modalities) but is not used as a heating method, so it is
included here under the non-thermal applications. At
some point there might be a need for a ‘new’ mechanical
energy group (shockwave, whole body vibration, deep
oscillation therapy), but that would leave ultrasound
448
either in the ‘wrong’ group or dissociated from its thera-
peutic partners.
Shockwave therapy
Shockwave therapy in the context of therapy practice is a
relatively recent development and, like LIPUS and micro-
current therapies, is rapidly gaining ground both in
research and in practice terms. This section only aims to
provide a brief overview of this treatment approach. At the
present time, it remains unclear who the dominant users
of this treatment will be – specialist technicians, orthopae-
dic surgeons or physiotherapists.
Shock waves were initially employed as a non-invasive
treatment for kidney stones (from the early 1970s, with
treatment proper starting in the 1980s) and it has become
a first-line intervention for such conditions. In the process
of the animal model experimentation associated with this
work, it was identified that shock waves could have an
(adverse) effect on bone. This led to a series of experimen-
tal investigations looking at the effect of shock waves on
bone, cartilage and associated soft tissues (tendon, liga-
ment, fascia) resulting in what is now becoming an inter-
vention of increasing popularity, most especially for the
recalcitrant lesions of these tissues.
The treatment goes by several names, the most popular
being shockwave therapy or extracorporeal shockwave therapy,
though, as ever, there are several variations, often linked
to the names of particular machines and systems. Obvious
examples of shock waves are the sonic boom from an
aircraft, thunder or the sound following an explosion. A
very readable but succinct history of the development of
shock waves for medical applications can be found in
Thiel (2001).
Basically, there are three different ways to produce the
‘shock wave’, which, without getting too technical are:
spark discharge/piezoelectric, electromagnetic and pneu-
matic (ballistic). The wave that is generated will vary in its
energy content and will also have different penetration
characteristics in human tissue. The pneumatic (ballistic)
generators produce a gently divergent wave which appears
to have the better options in ‘therapy’ (the other genera-
tors normally generate a focussed beam, mainly for non-
therapy applications).
A clinically useful shock wave is effectively a controlled
explosion (Ogden et al. 2001) and when it enters the
tissues, it will be reflected, refracted, transmitted and dis-
sipated like any other energy form. The energy content of
the wave will vary and the propagation of the wave will
vary with tissue type. Just like an ultrasound wave, the
shock wave consists of a high pressure phase followed by
a low pressure (or relaxation) phase. When a shock wave
reaches a ‘boundary’, some of the energy will be reflected
and some transmitted.
The characteristics of a clinical shock wave are (Ogden
et al. 2001; Speed 2004):

• peak pressure (typically 35–120 MPa);
• fast pressure rise (usually <10 nanoseconds);
• short duration (usually about 10 microseconds);
• narrow effective beam (2–8 mm diameter).
Broadly speaking, there are high and low power applica-
tions. The high power treatments (>0.6 mJ/mm2) are ‘one
off’ and generate a fair amount of pain such that some
form of local anaesthetic is usually needed for the patient
to be able to tolerate the treatment. The more common
approach in therapy is to use several (usually 3–5) applica-
tions at low power (up to 0.08 mJ/mm2 – no anaesthetic
required) with typically 1000–1500 shocks delivered per
session.
The pressure wave causes direct (linked to the high pres-
sure part of the cycle) and indirect effects (associated with
the subsequent low pressure part of the cycle during which
cavitation will occur – as with therapeutic ultrasound).
The collapse of these cavitations (bubbles) is, in part at
least, responsible for the efficacy of the therapy.
As the shock wave travels through a medium and comes
to an interface, part of the wave will be reflected and part
C
Figure 19.30  Examples of therapy-based shockwave machines and application: (a) Swiss DolorClast (Spectrum Technology);
(b) Shock Master (Gymna); (c) Lateral elbow shockwave therapy (Spectrum Technology).
Electrotherapy Chapter 19
transmitted. The dissipation of the energy at the interface
is almost certainly responsible for the generation of the
physical, physiological and thus the therapeutic effects.
While the detailed mechanisms of how these are achieved
remains elusive, there is a growing body of evidence
that supports the use of the therapy in several different
clinical areas.
In the therapy arena, the best evidence appears to be
with the chronic tendinopathies (e.g. Rompe et al. 2008,
2009) in which case shock wave therapy was shown to be
effective in isolation, but when combined with an eccen-
tric loading programme, better results were achieved. There
is also clinical evidence for fracture healing problems
(delayed or non-union) and numerous other soft tissue
clinical problems, especially those concerning ligament
and fascia. Useful reviews can be found in Chung and
Wiley (2002), Wilbert (2002), Mouzopoulos et al. (2007),
Rompe and Maffulli (2007) and van Leeuwen et al. (2009).
Examples of current therapy-type shockwave machines
and applications are illustrated in Figure 19.30.
As identified in the introductory comments, shock wave
is not yet a ‘normal’ therapy intervention, but it is likely
B
449
 Tidy’s physiotherapy

to move into common practice based on the rapidly
growing body of supportive evidence. Therapists applying
this modality at low power over several sessions appears
to be the most likely way forward and the early clinical
results are encouraging.
SUMMARY
In summary, electrotherapy has an evidence-based role
in physiotherapy practice. It has been the subject of con-
siderable debate over recent years, but the evidence base
identifying what it is (and what it is not) capable of
achieving is substantial. This chapter has attempted to
summarise the key modalities in use in the current clinical
environment, identified some emerging modalities and
has alluded to others. The gradual transition from the term
‘electrotherapy’ to a more encompassing term ‘electro-
physical agents’ is inevitable and to be welcomed.
Each modality will have a range of specific physiological
effects and these can be employed in turn to bring about
therapeutic effects. Modalities have some commonality
in terms of their modes of action and the modalities
have been grouped together in this chapter on that basis
– electrical stimulation modalities, thermal modalities
and ‘non-thermal’ modalities.
By employing an evidence-based clinical decision-
making model, it is possible to make rational and evi-
denced therapeutic decisions with regard to which
modality (if any) to use and when. The details of dose-
based decisions have been largely omitted from this text,
but making the appropriate decision with regard to which
modality to employ in particular circumstances is the first,
and probably the critical, choice. Once the most appropri-
ate modality has been identified, the specific treatment
‘dose’ needs to be identified. Research articles and stand-
ard electrotherapy texts are available in addition to online
resources to facilitate these detailed decisions.
The overuse of electrotherapy in the past has resulted in
the demise of this area of practice. This chapter has
attempted to identify the key issues for commonly avail-
able modalities, to illustrate their potential clinical appli-
cations based on the available evidence and to identify
detailed sources for further information.
Weblinks
Alpha Stim: www.themicrocurrentsite.co.uk
Body Clock Health Care Ltd: www.bodyclock.co.uk
Chatanooga (part of the DJO Group):
www.chattgroup.com/
Elexoma: www.elexoma.com/
EMS Physio Limited: www.emsphysio.co.uk
Enraf Nonius: www.enraf-nonius.com
Gymna Uniphy: www.gymna-uniphy.com/
Indiba: www.indiba.com
Natures Gate: www.naturesgate-uk.com/
Neurotech: www.neurotech.co.uk/
Smith and Nephew (Exogen): global.smith-nephew.com
Spectrum Technology: www.spectrumtechnologyuk.com
Synapse Tendonworks: www.tendonworks.com/index.html
TensCare Ltd: www.tenscare.co.uk
THOR International: www.thorlaser.com/

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 Chapter
Physiotherapy for people with major amputation
Carolyn A. Hale
INTRODUCTION
Rehabilitation following amputation is the responsibility
of the multi-disciplinary team (MDT), with the patient
focussed in the centre. Working with a specialist team will
produce the best outcome for the individual who has
undergone life-changing amputation surgery (Pernot
1997). The physiotherapist is a key member of this team,
involved at all stages of the process from the pre-operative
phase, through amputation and discharge home, to pros-
thetic training and during life thereafter.
This chapter provides an overview of the physiotherapy
management of people with amputation, outlining the
role and importance of the physiotherapist’s intervention.
Readers will need to refer to the appropriate texts for
details of specific treatment modalities and knowledge of
causative factors, surgical techniques, prosthetic compo-
nentry and associated equipment. A list of reading mate-
rial and resources will help you source this information,
as will many of the other chapters in this book. This
chapter will predominantly address the management of
adult lower limb amputation.
Amputation is performed for life threatening disease,
pain or unsalvageable injury, where all other treatments
have failed. The goal is to preserve life and improve func-
tion and general health. Having a limb amputated is a
life-changing event with potentially devastating conse-
quences to every aspect of living, not just physical func-
tioning. Becoming disabled in this way can affect a person’s
personality: affecting body image and relationships, and
sometimes threatening the family unit. If amputation
occurs when someone is of a young age it can affect
earning potential and ambition, and, in most cases,
can result in the person having to move home to more
suitable accommodation. For many, meeting these chal-
lenges is the incentive that drives the determination to
overcome their physical disability to achieve a good
quality of life.
20
CAUSES AND LEVELS
OF AMPUTATION
According to the Limbless Statistics (currently replacing
the National Amputee Statistical Database, or NASDAB,
and managed by UNIPOD), over 72% of lower limb
amputations performed in the UK are as a result of
vascular deficiencies, such as peripheral arterial disease
and/or diabetes (Van de Ven and Engstrom 1999),
whereby 50% of these people have diabetes. In fact, this
is the case for the majority of lower limb amputations
performed in the Western world (Ebskov 1999). Most
patients in this category will be over the age of 65
years and may have other comorbidities associated
with the ageing process and vascular dysfunction, such
as arthritis and cardiac disease (Fyfe 1992, Ham and
McCreadie 1992). As most vascular pathologies are pro-
gressive in nature, the patient may have undergone
earlier intervention in the form of arterial bypass opera-
tions (to relieve blockages and narrowing in arteries) or
toe amputations (as a result of tissue death) prior to
a major amputation. When planning a treatment
regime, these concurrent pathologies and history must
be accounted for.
The next most common cause of amputation is trauma,
where an individual has, perhaps, been involved in a road
traffic accident or industrial incident. Amputation may be
the only option if the injury to bone, soft tissue, blood
vessels and/or nerves cannot be treated and made viable.
Amputation may be at the time of the accident or, in some
cases, days, months or even years afterwards, when the
injured part becomes a burden.
Trauma is the major cause of upper limb amputation,
which is often a result of a work-related accident. This
population of patients are usually therefore young and of
working age. Overall, however, people with amputation
owing to trauma remain a very small population in com-
parison with those with vascular issues.
457
 Tidy’s physiotherapy
Table 20.1  Causes of amputation in the developed
world (Van De Ven 1999)
Developed world cause Relative
percentage (%)
Lower limb
Peripheral arterial disease 85–90
(25–50% of which also have
diabetes mellitus)
Trauma 9 Chopart/Lisfranc
Tumour 4
Congenital deficiency 3
Infection 1
Upper limb
Trauma 29
Disease 30
Congenital deficiency 15
Tumour 26
Historically, the field of prosthetic limbs develops sig-
nificantly at times of war owing to the increased demand
for such services by the young war-injured. Injuries caused
by bomb blasts are particularly challenging for the MDT
owing to the extensive nature of injury.
Other reasons for major amputation of an arm or leg
are tumours, infection and congenital deficiencies. Chil-
dren born with limb absences or deformity do not always
have an amputation; however, their limb dysfunction is
often managed like an amputation. In general, it is fair to
say that people born with full or partial limb absence cope
better mentally and physically with their impairment than
someone with acquired limb amputation – particularly
those with upper limb involvement who tend to be less
reliant on a prosthesis.
The decision regarding amputation level is determined
by the need to remove all non-viable tissue while creating
a healed, pain-free, functional and potentially prostheti-
cally suitable residuum (stump), also called residual limb.
Incidentally, many patients do not like their leg being
referred to as a ‘stump’ and appropriate references should
be found. Where possible, when an amputation is a
planned event, the physiotherapist should be involved in
the amputation level decision as their assessment findings
can predict postoperative functional ability and therefore
the likely rehabilitation outcome. Tables 20.1 and 20.2
list the causes of amputation seen in the developed world
and the recognised levels of surgical amputation.
458
Table 20.2  Levels of amputation (Van de Ven 1999)
Lower limb Upper limb
Hemipelvectomy Forequarter
Hip disarticulation Shoulder disarticulation
Transfemoral* Transhumeral*
Supracondylar, transcondylar Elbow disarticulation
and Gritti-Stokes Transradial*
Knee disarticulation Wrist disarticulation
Transtibial* Transmetacarpal
Symes Interphalangeal
Transmetatarsal
Interphalangeal
*Denotes the most commonly seen levels in clinical practice.
Key point
The MDT consists of surgeons, nurses, physiotherapists,
occupational therapists, counsellors and psychologists,
prosthetists and orthotists, wheelchair therapists,
rehabilitation doctors, podiatrists and chiropodists, social
workers and homecare agencies. Specialist regional units,
sometimes known as Disablement Services Centres
(DSCs) are the usual hub of management. Services are
provided by primary, secondary and tertiary
establishments, and the patient will meet numerous
clinicians throughout their rehabilitation. The
physiotherapist has a key role, often providing the
constant link between all the professionals.
THE PSYCHOSOCIAL IMPACT
OF AMPUTATION
The physiotherapist, as for all team members, must have
an understanding of the psychological implications as­­
sociated with having a limb amputated. This will help
in building a rapport with the patient, aiding agreed
goal-planning and facilitating a motivating rehabilitation
regime for the individual.
Loss of a body part and consequent change to
body image can potentially lead to loss of confidence;
loss of function; loss of a lifestyle; loss of role, income
and status; and loss of independence and control. Having
an amputation can result in people feeling vulnerable,
worthless and isolated. People will be affected by each
of these aspects to differing degrees and their ability to
accept their new situation will also vary greatly. The
normal reactions to grief and bereavement are well docu-
mented (Kubler-Ross 1969; Parkes 1972, 1975; Campling
1981); for some patients the reaction is transient and
 Physiotherapy for people with major amputation
minor, while for others it is profound, disabling and
longer lasting (Bradway et  al. 1984; Butler et  al. 1992;
Krueger 1984).
Key point
Models of grief and bereavement offer frameworks for
understanding grief associated with loss. It must be
recognised that grief affects people in different ways and
does not always manifest itself in a set pattern to a set
timeframe. The physiotherapist must be sensitive to
patients’ emotional needs at all stages of the
rehabilitation process.
Anyone who has an amputation needs to be given time
to adjust. They need to be given accurate information
about their rehabilitation programme and realistic ideas
of what they can expect. Amputation affects the whole
family and loved ones should be included in any rehabili-
tation process (Caron 1989). A successful outcome in
restoring independence and self-worth is dependent on
adjustment and acceptance by the individual and their
close support network. People with disability often lack
choice and other people make decisions on their behalf
(O’Shea and Kennelly 1996). This has the impact of
denying them a role in society. The physiotherapist must
take time to talk with their patient, to understand their
fears and their hopes, to recognise barriers to progress and
work together to set goals. Recovering after an amputation
is not just about functional recovery, for example being
able to ‘walk’ or to make a cup of tea.
PAIN AND PAIN RELIEF
There are three potential types of pain following
amputation.
Residual limb pain
Amputation surgery creates tissue disruption and trauma.
This produces a natural inflammatory response resulting
in oedema (swelling). Refer to Chapter 12 for details.
The oedema results in pressure on already injured nerve
endings, causing pain. This pain is usually managed
postoperatively with analgesics and possibly epidurals.
Managing the oedema itself will also help with pain
relief. The physiotherapist can use limb elevation, elastic
compression such as Tubifast, intermittent compression
and exercise to improve the circulation thereby promoting
the healing process, reducing swelling and thus pain (see
Figure 20.1). Normal primary healing takes around three
weeks. Any delays in healing can result in greater scar
tissue which can become adherent to the underlying bone
Chapter 20
Figure 20.1  Elevation with a wheelchair stump board and
compression garment.
and therefore be painful on skin movement, especially
when under pressure. Massage and ultrasound can be
helpful at relieving this type of scar pain.
Following amputation, when a cut nerve heals there is
a growth of nerve cells at the distal end. As the dissected
nerve has no neural sheath to grow into it forms a bundle
called a neuroma. The surgeon endeavours to bury major
nerve endings within soft tissue, as they can be very sensi-
tive. If the neuroma is superficial, direct pressure from
wearing a prosthesis can create pain. Sometimes ultra-
sound therapy can ease symptoms.
Later on, use of a prosthesis can cause pain in the
residual limb owing to sheer friction or excessive pressure.
This can damage skin, which can result in bruising, skin
breakdown, infected hair follicles and blisters. The physi-
otherapist must ensure that the user has put it on cor-
rectly and ensure a correct fit. Liaison with the prosthetist
is essential (see the section related to prostheses further
on in the chapter). Skin hygiene and skin care is also
very important.
Phantom limb pain and sensations
Phantom limb is described as sensation experienced in the
missing limb part (phantom limb sensation (PLS) ) and it
can, in many cases, be experienced as pain (phantom limb
pain (PLP) ). It is well documented and symptoms are well
recognised, if not poorly understood (Fraser et al. 2001).
It is a feature that can impact significantly on the life of a
patient (Hill et al 1995; Weiss and Lindell 1996; Williams
and Deaton 1997). Experiencing a phantom limb can be
alarming to people and they need to be reassured that this
is normal, as 70% of people with amputation experience
PLP (Butler and Moseley 2008).
459
 Tidy’s physiotherapy
There are two reasons why someone may still perceive
the amputated body part. Firstly, the brain has an area of
tissue dedicated to that body part (the homunculus map)
which expects sensory information. This area of the brain
is obviously not removed during limb amputation and
thus still tries to process information. As a result, it
can acknowledge sensory input from the adjacent brain
tissue. When the sensory feedback is painful, this can be
more troublesome for the individual as it is perceived
as real pain.
A second reason to perceive pain is owing to the surgical
cut of the nerve causing damage and inflammation. In
addition, at the time of injury or disease, the nerve tissue
may have been crushed or starved of a vascular supply, also
resulting in painful symptoms.
Types of phantom pain described are: ‘burning’, ‘elec-
tric’, ‘shooting’, ‘twisting’, ‘cramping’, ‘crushing’ and
‘sharp’. PLP can be intermittent or constant, and can be
felt in any part of the removed limb. This can take a long
time to settle down and in a few cases never resolves.
It can seem worse when the individual is stressed or
unwell, throughout a lifetime. It is important that the
physiotherapist assesses pain carefully to determine its
cause and allay patient fears that something is wrong.
Effective pain relieving modalities for phantom include:
transcutaneous electrical nerve stimulation (TENS), acu-
puncture, relaxation, massage, exercise, compression and
analgesia. Chapter 17 (‘Pain’) will be useful to consult.
Alternative methods can include reflexology, counselling
and hypnotherapy.
Key point
Phantom pains are often exacerbated by stressful life
events, such as illness, changing house or job, or divorce
and bereavement.
PLP should not be confused with PLS, which are sensa-
tions in the missing limb that are not painful. These are
often sensations of the limb as it was before amputation,
often in normal orientation, but sometimes in a strange
position. People have described such sensations as ‘foot
facing backwards’, ‘tight shoes’, ‘itching’ and ‘pins and
needles,’ as well as feeling that their hand or foot is now
at the end of the residual limb, known as the telescoping
effect. These sensations can be equally distressing and as
distracting as phantom pain.
Secondary pain
Another significant area of pain can be the secondary pain
caused by the stress to the remaining musculoskeletal
system, owing to the asymmetry of the posture caused by
amputation and the use of a prosthesis. It is well known
that lower limb prosthetic users are prone to early onset
osteoarthritis, particularly in the lower back and in the hip
460
and knee on the remaining side (Ehde et al. 2001; Norvell
et al. 2005) Your skills in the assessment and management
of musculoskeletal problems will be vital.
THE ROLE OF THE PHYSIOTHERAPIST
FOLLOWING LOWER LIMB
AMPUTATION
Physiotherapy involves the continuous assessment of
patients’ goals, needs and abilities in order to set realistic
and agreed treatment plans. The physiotherapist will rely
on all their skills for treating a number of conditions.
The physiotherapist must re-educate movement pat-
terns to optimise independent function for activities of
daily life such as self-care, wheelchair and prosthetic use,
and normal occupation, while managing all influencing
factors.
Physiotherapy aims
Rehabilitation following lower limb amputation is a con-
tinual process, involving all aspects of a person’s life:
physical, mental, emotional and socioeconomic. For a suc-
cessful physiotherapeutic outcome all these aspects must
be addressed.
The final goal should be optimal independence, with or
without a prosthesis, to return to as normal a life as pos-
sible. Ideally, the person should achieve:
• independent self-caring;
• independent indoor mobility;
• independent outdoor mobility;
• being able to get in/out of a car or other transport;
• a return to leisure/hobbies/work/society.
Considerations
The following are reasons why some patients have difficul-
ties achieving goals:
• poor residual limb condition, e.g. adherent scar
tissue, unhealed, bulbous shape, failed myodesis,
neuroma, bony prominences, pain, hypersensitivity,
poor vascularity, short leverage, skin frailty;
• concurrent pathologies leading to an inability to
learn, reduced range of motion, reduced strength
and stamina, pain, poor balance, poor dexterity,
socket intolerance;
• social and environmental difficulties, e.g. living
alone, unsuitable accommodation for wheelchairs or
prostheses, poor access to accommodation,
unhealthy lifestyle, dominant carers;
• lack of motivation – fear, fatigue, emotional barriers
to achieving success;
• inappropriate equipment, e.g. poor prosthetic socket
fit or alignment, a too big or too small wheelchair,
incorrect prescriptions;
• lack of specialist rehabilitation services.
 Physiotherapy for people with major amputation Chapter 20

The inability to learn new skills is probably the largest

determining factor to successful outcome. Sometimes this
can be influenced by physiotherapy intervention but not
in every case.
Patients must be involved in co-ordinating all aspects of
their treatment-planning, goal-setting and monitoring as
self-responsibility and self-management are the founda-
tions of rehabilitation (Watson 1996).
PHYSIOTHERAPY ASSESSMENT
Assessment
A thorough subjective and objective assessment will
ensure accurate and realistic goal planning. Table 20.3
outlines the content of both a subjective and objective

Table 20.3  Recommended content of assessment following amputation

Subjective assessment

Present complaint Level of amputation and cause, time since amputation. Current symptoms

History of present Ulcers, gangrene, bypass surgery, intermittent claudication, rest pain, sympathectomy,
complaint embolectomy, heparinisation, stages of amputation. Accident details and orthopaedic
history, salvage operations, oncology treatment

Past medical history Related: diabetes, myocardial infarction, cerebrovascular accident, angina, renal status,
eyesight and neuropathy, concurrent injuries
Other: respiratory disorders, osteoarthritis, rheumatoid arthritis, major surgery, old injuries,
hearing and sight, depression, epilepsy, low back or peripheral joint pain

Social history Home environment, cohabiters, family support and dependants, home care package, district
nurse, access (ramps), doorways, bathroom upstairs, rails/stair lift, employment, school
and education, hobbies, finances, compensation claim status (related to trauma), driving,
smoking and lifestyle, attitude to exercise and fitness

Drug history Drugs that may affect rehabilitation programme

Mobility Pre-amputation – distance covered, walking aids used, stairs, outdoors, wheelchair, exercise
and sports, limiting factors
Post-amputation – as above plus transfers and bed mobility
Type of wheelchair, walking aids and prosthesis

Function Self-care, domestic tasks, shopping, laundry, carrying objects, picking up objects, stairs, steps/
kerbs, slopes, energy expenditure, limiting factors, compensations, safety, falls, aids used

Prosthetic rehabilitation Current and previous prostheses: prescription, delivery date, socket fit, ability to don/doff,
history maintenance, pattern of use (how long, daily, how far) and reasons for no prosthesis.
Current and previous physiotherapy intervention

Psychological status Attitudes, emotions, depression, goals and aspirations

Objective assessment
Residual limb Wound, scar, healing status, dressings, oedema, pain (visual analogue scale 0–10*),
sensation, colour, temperature, compression therapy, reflexes, joint range, contractures,
weakness, strength, co-ordination

Remaining limb Vascularity, strength, joint range, scars, wounds, risk level, temperature, ulcers, footwear,
colour, pulse, pain, oedema, numbness, joint dysfunction and adaptations, sensation,
reflexes, motor control

Trunk and balance Sitting, standing, pain, trunk range and control of movement, alignment, posture and core
stability, abdominal strength, compensation reactions (see Figure 20.2 – postural
alignment changes following amputation)

Gait/function with Gait pattern, deviations and possible causes, speed, indoor and outdoor use, varying
prosthesis surfaces, exercise tolerance

*0 denotes no pain and 10 denotes worst pain imaginable.

461
 Tidy’s physiotherapy
assessment. It is important during the assessment that
the physiotherapist gains an understanding of what the
patient has been through, their current situation and their
goals for the future. This needs to be in terms of their
physical and psychosocial well-being. The objective as­­
sessment needs to carefully assess any musculoskeletal or
neurological dysfunction and current movement control.
Following amputation, the skeletal system makes com-
pensations for the imbalance caused by the missing
anatomy or the restrictions caused by the prosthesis. Joint
alignment and soft tissues adapt to new prolonged pos-
tures. Muscles can start to work inefficiently and in an
uncoordinated manner, affecting a person’s ability to
move safely (Comerford et al. 2005). See Figure 20.2
Figure 20.2  Common postural changes following
amputation.
462
to see the likely postural shift in someone with a lower
limb amputation. The head centralises over the remaining
heel and the foot has rotated outwards for increased
stability. In some cases, such postural changes can result
in pain. The altered biomechanics can result in increased
energy expenditure and loss of confidence when moving.
Restoring midline alignment aids the most efficient
muscle recruitment.
Problem list
Based on findings from assessment, the problem list is
formulated with agreed and realistic goals, for both the
short and the long term.
Treatment plan
A treatment plan is drawn up in order to achieve the
desired goals based on the assessment findings.
Key point
Frequent reassessment will guide any revision of goals.
Physiotherapy treatment is concerned with teaching
people new skills. It is a partnership, not related to
‘doing to the patient’ but related to the patient learning
to do things for themselves.
STAGES OF PHYSIOTHERAPY
MANAGEMENT
The physiotherapist acts as part of the MDT and is involved
at all stages of the amputation management, as summa-
rised in Table 20.4. It is important that the physiotherapist
liaises with all members of the team at the different stages
of the rehabilitation process in order to gain best outcome
for their patient and have common agreed goals.
Pre-operative stage
In cases of planned surgery it should always be possible
for the physiotherapist to assess the patient before their
amputation. The physiotherapy assessment should be
holistic, assessing sensory and motor performance, in­­
cluding respiratory status and function, while addressing
current and pre-morbid levels of independence and psy-
chological well-being.
As part of the MDT, the physiotherapist should be
involved in the decision as to what level to amputate and
in the preparation of the patient for surgery (Cutson and
Bougiorni 1996). Exercises and wheelchair or crutch use
can be taught at this stage if the patient is not in too
 Physiotherapy for people with major amputation Chapter 20

Table 20.4  Summary of stages of physiotherapy management

Stage of Aspects
management

Pre-operative Physical, functional and psychological assessment prior to surgery to inform decision of level to
amputate
Provision of pre-operative exercises in preparation for postoperative period
Provision of information about rehabilitation process
Wheelchair and mobility practice

Postoperative Physical and functional assessment

Address pain and oedema control
Practise transfers and independent function
Practise use of walking aids and wheelchairs
Promote wound healing, pressure care and good nutritional intake
Provision of exercises for strengthening, stretching and balance in order to aid independent mobility
Provide education and information for patient and carers
Liaise with MDT within the hospital and community
Refer to appropriate agencies for discharge

Pre-prosthetic Prosthetic preparation: compression and shaping of the residual limb using elasticated stocking,
elevation, exercise and early walking aids
Improve cardiovascular fitness
Provide education and information for patient and carers
Liaise with MDT within the hospital and community
Refer to appropriate agencies for prosthetic provision

Prosthetic Physical, psychological and functional assessment

Provision of exercises for strengthening, stretching, stability and balance
Gait re-education to minimise gait deviations, achieve safe mobility and promote energy efficient
function
Continue pain control measures
Progress walking aids and skills with the prosthesis
Practise activities of daily living (dressing, cooking, walking outdoors, shopping) as part of MDT
Information regarding care of the residual and remaining limbs and prosthesis

Lifelong Maintenance exercises

Further intervention when the situation changes
Review appointments to reassess
Liaise with community agencies
Facilitate reintegration to normal living
Act as long-term resource for patients, families and carers

much pain. As the quality of the amputation surgery can
influence final rehabilitation outcome, the surgeon is an
integral member of the team.
Both the patient and their family will benefit from infor-
mation about the rehabilitation process and what to
expect (Yetzer et al. 1994). At this time it is helpful to
spend time with the patient, reassuring them and building
a rapport. This will be advantageous in the postoperative
stage.
Postoperative stage
Once the person has had their amputation, they are
usually brought back to the main ward. Only if there are
comorbidities or complications are they transferred to
high-dependency or intensive care units.
Ongoing physiotherapy assessment needs to take place
at all stages. At many operating hospitals a care pathway
is in place which will outline how the immediate postop-
erative phase should be managed. The physiotherapist can
be guided by this, applying it to the individual patient’s
needs. An example of such a pathway can be found in
Table 20.5.
Early mobility is important to prevent weakening, stiff-
ness, loss of balance and confidence, especially in the
elderly. It is common practice to get out of bed on day two
after amputation. This immediate re-education of posture
and balance provides a big psychological boost.

463
 Tidy’s physiotherapy
Table 20.5  Example care pathway for early
rehabilitation following lower limb amputation
Day 1: In bed
Respiratory care, pain control exercises for bed mobility
and joint range
Day 2: Sit out in chair
Range of movement and strength for all limbs and trunk
Balance training
Transfer practice and wheelchair provision
Oedema control
Day 3: Independence
Continue exercises for strength, range and balance
Pain and oedema control
Functional exercises, i.e. bridging and supported
standing, wheelchair, personal care
Posture correction
Days 4–7: Discharge planning
Plan home visit with occupational therapist
Monitor oedema control
Continue exercise programme and mobility
Ensure appropriate clothing for rehabilitation
Days 7–14: Prosthetic assessment
Attend gym environment, individual and group
exercise sessions
Assess and practise with early walking aid, i.e. pneumatic
post-amputation mobility (PPAM) aid
Prepare for prosthetic rehabilitation: stump shape,
balance, proprioception and strength
Refer to regional prosthetic centre
Discharge or transfer to rehabilitation ward or
intermediate care
Days 14–28: Develop appropriate plan
Progress rehabilitation programme: prosthetic or
non-prosthetic
Weeks 4–6: Outpatient or community
Cast for prosthesis
Start prosthetic training
Ensure reintegration into home environment
Controlling residual limb oedema is vital to postopera-
tive progress. A reduction in swelling will reduce pain,
improve compliance, aid healing and prevent delays to
rehabilitation. Compression, exercise and positioning in
elevation will aid in oedema control.
Key point
Residual limb shape is important for making a prosthetic
socket and can be determined by using a Juzo
compression garment (www.juzousa.com), which controls
the oedema. The correct sizing of such a garment is
essential and should be measured by a suitably qualified
practitioner (Lambert and Johnson 1995).
464
In the early stage following amputation a person will be
very keen to learn to be independent. Practising use of a
wheelchair, and transferring to and from it safely are
important activities. Most people with unilateral amputa-
tion will stand on their remaining limb to pivot into the
chair positioned at 90 degrees, with or without the armrest
being removed. Protective footwear is necessary for this
transfer technique. Sliding boards are a useful tool where
patients are too weak to lift their own body weight or
where their remaining limb is not suitable. Figure 20.3
demonstrates a forwards/backwards transfer suitable for
someone with bilateral lower limb amputations. Crutches
or frames are suitable for those with excellent balance and
upper limb strength, although this raises the risk of falls
and residual limb oedema owing to the dependent posi-
tion while mobilising.
As an integral member of the team and using a holistic
approach the physiotherapist should also play their part
in pressure-management of vulnerable tissues at this time
of relative immobility and encourage adequate nutrition
to aid postoperative recovery.
An essential role of the physiotherapist at this stage is
to encourage normal movement patterns and prevent joint
contracture. Reduced joint range can be painful, delaying
rehabilitation and, in severe cases, can prevent prosthetic
fitment. The physiotherapist educates the patient in exer-
cises for joint stretching and posture care. The common
contractures in lower limb amputation affect both the hip
and knee joints and are associated with pain and pro-
longed sitting positions:
• transtibial level – contracture of the knee into a
flexed position. Active knee extension should be
encouraged, with passive stretching, and positioning
provided by elevation on the bed or stump board, as
shown in Figure 20.1;
• transfemoral level – contracture of the hip into a
flexed position. There may also be a contracture into
abduction, where the hip flexors and abductors are
unopposed by weakened extensors and adductors.
Active exercise of the weak muscles and positioning
will help to address this imbalance.
Hip flexion contractures can also commonly occur in
transtibial amputations. Figure 20.4 shows how a small
stool can be used to strengthen groups of muscles, creating
better balance between opposing muscles, therefore reduc-
ing the incidence of joint contractures.
Re-educating postural balance and control will con­
tribute to safe mobility, whether with a wheelchair,
crutches or prosthesis. A gym ball is a great adjunct
for developing a person’s core stability and control, as
Figure 20.5 demonstrates.
Reassuring patients and repeating information will
allay fears and help them to concentrate on their reha­
bilitation programme. Liaison with colleagues and dis-
charge agencies is necessary to facilitate smooth progress.
Continuing rehabilitation into the community will
 Physiotherapy for people with major amputation
Figure 20.3  A forwards/backwards transfer suitable for
someone with bilateral lower limb amputations.
Figure 20.4  Combined muscle strengthening to control joint
range.
Figure 20.5  Use of a gym ball to aid trunk rehabilitation.
Chapter 20
encourage adaptation to new skills of independence aided
by the familiar surroundings (Park et al. 1994).
Pre-prosthetic stage
Once it has been decided that someone has the potential
ability to use a prosthesis, the pre-prosthetic preparation
should start. The person may still be an inpatient, at home
following discharge or they may be at an intermediate care
facility. It is worth mentioning that almost half of people
undergoing amputation in the UK are not suitable for
prosthetic prescription owing to comorbidities, such as
respiratory or cardiac incapacity. Exercises should be pro-
gressed to challenge the posture and balance in a more
upright position. Use of early walking aids, equipment
that offers bipedal gait without a prosthesis, promotes
oedema reduction and wound healing, and provides
an insight for patients and therapists as to how well
someone will progress. Over 80% of UK physiotherapy
departments have early walking aids called pneumatic
post-amputation mobility (PPAM) aids (www.ortho-
europe.com; Lein 1992), whereby the patient’s residual
limb is surrounded by an inflatable bag within a metal
frame by which they can carry some weight on the
amputated side. The bags are inflated to 40 mmHg in a
non-weight-bearing position, which is known to be a pres-
sure that will not cause tissue damage when applied in a
constant manner. Walking with a PPAM aid should
be partial weight-bearing and always initiated within
the parallel bars. In vascular cases this should be intro-
duced at day 7–10 post-operation, and is suitable for tran-
stibial, knee disarticulation and long transfemoral levels
of amputation (see Figure 20.6). The physiotherapist
should always follow the manufacturers’ instructions and
national guidelines (see Further Reading).
A second type of early walking aid is a Femurett (manu-
factured by Össur) which is designed for use with trans-
femoral amputations. Össur have produced a training
guide and video in collaboration with the British Asso­
ciation of Chartered Physiotherapists in Amputee Reha-
bilitation (BACPAR). This type of walking aid can be
used in full weight-bearing and is commonly found at
the regional limb centres.
Prosthetic stage
Being able to use a prosthesis can allow a person to enjoy
a greater quality of life, possibly being rid of years of pain
and poor function from a diseased or injured limb, and
being able to return to work and leisure activities. At this
stage of rehabilitation an intensive gait re-education
programme is necessary. Early prosthetic fitting and reha-
bilitation are vital to successful physical, emotional
and psychological recovery in the short and long term
(Bradway et al. 1984).
Using a prosthesis well is about learning a new motor
skill, similar to learning to play the piano, play tennis or
465
 Tidy’s physiotherapy
Figure 20.6  Use of PPAM aid within parallel bars.
ride a bicycle. The prosthetic user needs to move with the
equipment. It takes hours of practice to be, and remain,
competent. Natural ability influences the final outcome to
some degree; however, effective training by a physiothera-
pist makes a huge impact.
The safe environment of the parallel bars is provided
initially for walking, progressing from here so as not to
encourage dependence on the bars in terms of partial
weight-bearing or fear of walking beyond this environ-
ment. Tension increases fatigue so patients are always
advised what is happening and what is expected from
them. All movement is observed carefully to assess what
is not normal, why that may be and whether it can be
improved.
An essential aspect to using a prosthesis is being able to
fully weight-bear through the socket. In addition, the user
must develop their proprioception to feel contact with the
ground through the socket, in order to confidently move
over the prosthetic foot. Appropriate motor output relies
on sensory input. Learning to recognise stimuli at low
thresholds forms effective proprioception, leading to
normal recruitment of muscle activity and balance reac-
tions. A comfortable socket is vital to achieving full
loading and control. Exercises should be used to facilitate
correct muscle recruitment, in particular to create pelvic
excursion and to stabilise body segments, especially at the
hip on the amputated side. Figure 20.7 shows how step-
ping onto a block with the remaining leg can encourage
466
Figure 20.7  Exercise for controlling weight-bearing and
weight transference.
weight-bearing and weight transfer over the prosthesis,
using hip abductors and extensors. Figure 20.8 shows how
the physiotherapist can facilitate rotation of the pelvis
around the longitudinal axis necessary for forward pro-
gression. Being able to stabilise the body while standing
on the prosthesis is necessary also for safe, confident
movement and can be encouraged using dynamic surfaces,
such as a wobble cushion (see Figure 20.9). The Nintendo
Wii Fit has become a useful adjunct to the physiothera-
pist’s tool kit, as balance exercises can help someone to
normalise their posture and control body movements
through fun, visual feedback. Guidelines are available.
During prosthetic training, the physiotherapist is
responsible for teaching the user how to care for their
residual and remaining limbs. This is particularly im­­
portant for people with diabetes, whose lack of foot
sensation puts them at great risk of a second amputation.
How to care for the prosthesis, understanding how the
 Physiotherapy for people with major amputation
Figure 20.8  Facilitation of pelvic rotation.
Figure 20.9  Hip stabilisation exercises.
Chapter 20
components function and how to don the socket properly
is key to successful use. Prevention of pressure sores will
ensure continued use of the prosthesis. The physiothera-
pist must also make their prosthetic rehabilitation pro-
gramme functional and orientated to the individual’s
lifestyle. Where appropriate, getting on and off the floor,
using transport and walking outdoors over uneven ground,
slopes, stairs and kerbs should be included, as well as tasks
around the home.
Key point
Specialist prosthetic training is essential to the success of
the rehabilitation programme. Readers are directed to
numerous texts containing specific knowledge of
prosthetic products, the normal gait cycle and gait
training techniques.
For some people having a prosthesis can be more of
a hindrance than a help. Learning to use a prosthesis
requires strength, co-ordination, cardiovascular fitness,
motivation and cognitive ability. Prosthetic abandonment
is common. At long-term post-amputation evaluation
approximately half of transtibial and less than a third of
transfemoral amputees use their prosthesis full-time (De
Luccia et al. 1992; Davies and Datta 2003). Wheelchair
independence is a more appropriate option for many
elderly amputees. Rehabilitation in a wheelchair must also
address independence in activities of everyday living and
social integration. There are many seated exercises, which
can be effective and fun. Working on physical strength,
agility and posture aids transferring skills and also pre-
vents secondary pain.
Lifelong stage
The physiotherapist will be involved in the long-term
management of a person with an amputation. Mainte-
nance exercises should be prescribed and monitored to
minimise secondary dysfunctions. Review appointments
to assess movement patterns can promote independence
and continued use of the prosthesis.
As people progress through life their needs will change,
facilitating the further input of the physiotherapist. Exam-
ples of such events are when the prosthetic prescription
changes, return to work and/or sport, issues related to the
ageing process or change in health status and problems
occurring as a result of postural compensations. People
with lower limb amputation commonly develop a loss of
control of hip and knee extension on the prosthetic side,
poor control of trunk and hip rotation and hip abduction,
and excessive use of spinal extension.
467
 Tidy’s physiotherapy

Regular reassessments will highlight when the physio-

therapist needs to refer on to the other professionals, and
a working link should be maintained with key MDT
members.

Falls
Following amputation, people are at a greater risk of
falling. It is reported that 54% of people with amputation
fall each year (Miller et al. 2001). It is an important
part of the physiotherapy management to address this.
The risk factors of falling should be assessed for. These
include vision, home hazards, confidence, walking aids,
medication, alcohol intake, cardiovascular and neurologi-
cal status, and the prosthesis. Managing falls in the older
population is well documented and can be applied to this
client group. Any treatment regime for people with ampu-
tation must include strengthening the anti-gravity muscles,
balance training and how to get off the floor. For those
who cannot get from the floor by themselves, they need
to learn a strategy of what to do in the event of a fall. Any
persistent unexplained falls must be investigated further.
There is a BACPAR guideline to further inform you.

PROSTHESES

The prosthetist is primarily responsible for deciding on the
type of prosthesis to be provided and its manufacture. The
rehabilitation doctor, physiotherapist and occupational
therapist are also key in deciding what functions are most
appropriate and necessary for the potential user.
A prosthesis comprises: a bespoke socket, a form of
suspension, joint/s and interjoint segments, a foot or
hand/terminal device and a cosmetic cover. Examples of
transtibial and transfemoral prostheses without cosmetic
covers can be seen in Figures 20.10 and 20.11. The socket
must contain the remaining musculoskeletal tissues
(muscle, fascia and bone) and transmit the internal and
external forces involved in movement to the ground. A
comfortable and well-fitting socket is critical to a success-
ful prosthesis. Weight should be loaded on weight-tolerant
tissues and off-loaded in areas of pressure intolerance,
such as bony structures and nerves. Peak pressures and
friction will cause tissue damage and make the user reluc-
tant to wear the prosthesis. Teaching the user to don the
prosthesis correctly cannot be stressed enough.
The mechanics of the prosthesis can cause the user to
move in a certain manner. This can be very disconcerting
and it is the role of the physiotherapist to teach the user
to control the prosthesis and not be controlled by it. The
physiotherapist must be familiar with different facets of
prosthetic components and their provision in order to
teach best use. Close liaison with the prosthetist will
ensure an optimal outcome.
Figure 20.10  Example of a transtibial prosthesis.
PROSTHETIC GAIT DEVIATIONS
A sound understanding of normal gait will allow the phys-
iotherapist to analyse prosthetic gait and diagnose any
deviations. Chapter 15 (‘Biomechanics’) will provide the
required grounding. Prosthetic gait abnormalities are
caused by the user’s movement patterns or the prosthesis.
Often, it is the combination of both. The most common
gait deviations are described in brief below. This list is not
exhaustive.
Transtibial level deviations
• Excessive knee flexion during stance owing to weak
quadriceps and gluteals, fixed flexion at hip or knee,
excessive dorsiflexion at prosthetic ankle and short
prosthetic foot lever.
• Insufficient knee flexion during stance owing to poor
hip and knee control, socket discomfort and
excessive plantar flexion at prosthetic ankle.
• Lateral bending of the trunk to prosthetic side during
stance owing to socket discomfort, lack of hip
stability and a prosthesis being too short.

468
 Physiotherapy for people with major amputation
Figure 20.11  Example of a transfemoral prosthesis.
Transfemoral level deviations
• Abducted prosthesis, a wide base of support
throughout stance and swing owing to abduction
contracture, weak hip stabilisers, socket discomfort, a
prosthesis being too long, insufficient lateral socket
wall support and poor prosthetic knee control.
• Lateral bending of the trunk to prosthetic side during
stance owing to abduction contracture, short residual
limb, poor hip stability, insufficient lateral socket
wall support and too short a prosthesis.
• Circumduction, abduction through prosthetic swing
only owing to weak adductors, too long a prosthesis,
inadequate suspension, unstable prosthetic knee and
poor prosthetic knee control.
Chapter 20
• Vaulting, rising into plantar flexion through stance
on sound side owing to short residual limb, poor
prosthetic swing control, a prosthesis being too long,
inadequate suspension and too slow a gait.
• Excessive lumbar lordosis during prosthetic stance
owing to hip flexion contracture, weak abdominals
and hip extensors, unstable prosthetic knee and
insufficient socket flexion.
General observed deviations are uneven step length,
uneven timing and uneven arm swing. Using a prosthesis
requires energy expenditure in excess of normal walking
with two intact limbs. This can be very tiring. To compen-
sate, users will walk more slowly (Waters and Mulroy
2004; Hagberg et al. 2007).
The physiotherapist plays a pivotal role in training and
can influence the following causes of deviation: fear; weak-
ness; poor range of movement; poor weight-bearing; pain;
poor fit/donning; incorrect use; poor movement patterns
from incorrect muscle recruitment; fatigue; inappropriate
walking aids or their use; poor balance; change in foot-
wear; and bad habit/technique.
Prosthetic length and alignment issues are best identi-
fied and resolved with the physiotherapist and prosthetist
working together as a team. With respect to energy levels
and proprioception, it is far easier to rehabilitate with a
transtibial level amputation than a transfemoral level as
greater mobility can be achieved.
OUTCOME MEASURES
A physiotherapist should always have a benchmark by
which to measure whether the physiotherapy intervention
has been successful or not. This can be levels of pain, range
of joint motion or levels of function. Rehabilitation after
amputation is complex and multifaceted and measuring
the outcome can be problematic. There are a number
of outcome tools for disability that can be applied to
amputees. Described here are the tools validated specifi-
cally for prosthetic rehabilitation.
• SIGAM Algorithm (based on Harold Wood scale)
offers a simple, valid and reliable means of
measuring mobility in lower limb amputees. SIGAM
can be used throughout the stages of rehabilitation
to identify changes in mobility, making it useful
for both new and established amputees (Ryall
et al. 2003).
• Locomotor Capabilities Index (LCI) was designed to
trace a comprehensive profile of locomotor
capabilities of the lower limb amputee with the
prosthesis and to evaluate the level of independence
while performing these activities. The LCI is part of
the prosthetic profile of the amputee (PPA) (Grisé
and Gauthier-Gagnon 1993; Gauthier-Gagnon and
Grisé 1998).
469
 Tidy’s physiotherapy

• Trinity Amputee Prosthetic Evaluation Scale (TAPES) is a

questionnaire designed to investigate different
aspects of having an artificial limb (Gallagher and
MacLachlan 2004).
• Functional Measure of the Amputee (FMA) is a
questionnaire that was developed from the PPA
questionnaire, to collect long-term functional and
prosthetic use information following discharge. It
contains the LCI (Callaghan et al. 2002).
• Activities-Specific Balance Confidence Score (ABC UK) is
a self-completed questionnaire estimate (0–100%) of
how confident they are at certain activities, such as
picking things up off the floor, walking on a slippery
surface, reaching overhead and climbing stairs
(Powell and Myers 1995).
• The Amputee Mobility Predictor (AMP Pro) scores
components of walking in order to predict Figure 20.12  Running with transfemoral prosthesis.
outcome and guide the rehabilitation programme
(Gailey et al. 2002).
• Simple video recordings can be taken at stages of
rehabilitation as an aide mémoire and a tool for road traffic accident, an industrial injury, a domestic acci-
comparing change. dent or gunshot wounds. They can usually compensate
well and adapt physically to amputation but it can be
BACPAR have produced a tool kit of suitable outcome
a huge psychological blow. Rehabilitation plans must
measures which may be considered.
address their emotional needs, as many suffer from post-
traumatic stress disorder following horrific experiences. As
SPECIAL CONSIDERATIONS this patient group is young and active they have high
expectations for recovery and challenge the MDT to meet
their activity demands. Many need to return to work and
Children with amputation and sport (see Figure 20.12).
limb absence Patients involved in accidents can claim compensation
and may purchase their prosthetic rehabilitation from
Children with acquired amputation or congenital defi- private clinics. A claim can take many years to settle – a
ciency represent a highly specialised area in the field of trying time for the amputee.
prosthetic rehabilitation, as the numbers are relatively Those who have an amputation for cancerous tumours
small. Much of the physiotherapist’s time will be spent often face arduous treatment for the cancer at the same
reassuring, informing and teaching the parents (who may time as recovering from their amputation. Rehabilitation
be feeling very distressed and guilty about their child). A needs to be quick in cases where life expectancy is short-
child cannot be forced into using a prosthesis and many ened. An understanding of emotional status is imperative,
manage very adequately in life without one, especially at as coupled with the trauma of limb loss, the individual
upper limb levels. Adaptation throughout their life is has the life-threatening condition of malignancy to deal
dependent on acceptance of the deformity by those around with. It may be that ongoing cancer treatment will override
them, such as family, friends and teachers. Bipedal and any prosthetic rehabilitation.
bimanual activities should be encouraged as early as pos-
sible, to facilitate normal child development. Acquired
amputations pose different challenges than birth defects. Upper limb amputation
Each person and their family is unique.
Amputation at this level is most frequently seen in young
When involved in training a child, the therapist must
adults and the working population, where exposure to
make sessions fun and challenging. With upper limb
trauma is more likely. It tends to affect men more than
involvement, it is often the role of the occupational thera-
women. The second distinct group of patients requiring
pist to teach prosthetic use, whereby the physiotherapist
upper limb amputations is those with congenital limb
may manage any movement problems.
absence. In these cases, amputation is not always indicated
and a prosthetic socket can be fitted to the limb remnant.
Trauma and tumour amputation
Traditionally, upper limb prosthetic training is under-
People who undergo amputation for accidental injury are taken by an occupational therapist. If the amputation is
often of working age. Amputation can be the result of a on the dominant side, occupational therapy intervention

470
 Physiotherapy for people with major amputation
Figure 20.13  Transradial prosthesis at the fitting stage.
must be instrumental in promoting a change in hand
dominance. The physiotherapist’s role relates more to
exercising for strength, range and co-ordination, managing
oedema and offering pain-relieving modalities. Phantom
pain is as common in upper limb amputation as lower
limb, where people describe feeling their hand in the last
position prior to the traumatic event. Secondary dysfunc-
tions are common owing to overuse of the remaining arm
and because of poor movement and stability around the
affected shoulder girdle. Long-term posture exercises for
the residuum, remaining limb and trunk are important.
Arms and hands are used in social interaction, as tools
of expression and embrace. They are essential for provid-
ing comfort and for intimate self-care. An upper limb
amputation can be very difficult to adjust to. People
with upper limb amputations desire effective cosmetic
replacements, as well as functional tools. Usually, more
than one prosthesis is provided to meet these separate
goals. Figure 20.13 shows a transradial prosthesis prior to
completion. Some upper limb prostheses use body power
to move prosthetic joints, where others can use myoelec-
tric signals, sensed by electrodes within the socket, for
hand control. Skin-care and pressure-management within
the prosthetic socket, owing to gravity dependence rather
than loading as in the lower limb cases, requires equal
care and attention.
Complex cases
Due to the progressive nature of vascular disease, a third
to a half of people with amputations of this origin
will undergo a second amputation of their remaining
leg within a few years. Bilateral amputation is difficult
Chapter 20
at any age and requires considerable environmental
adaptations when the person is older and often
wheelchair dependent.
People presenting with multiple amputations including
extensive orthopaedic or neurological involvement pose a
real challenge to the physiotherapist. All the therapist’s
skills are required to teach independence in activities of
personal care and daily living. The whole MDT will need
to work together to address all aspects. Causes of multiple
limb loss are burns, meningococcal septicaemia, accidents
and combat. Often rehabilitation programmes must be
modified to accommodate associated skin damage and
muscle loss. Energy levels for ambulation are immense,
and sometimes, prosthetically prohibitive. The physiother-
apist must work hard at core strength and at stamina
levels. Rehabilitation using multiple prostheses can take
months if not years and the physiotherapist must remain
enthusiastic, focussed and motivating.
Walking with two lower limb prostheses at transfemoral
level of amputation can use more than 300% more energy
than if walking with their own two feet. Prosthetically, it
is good practice that someone starts on short rocker pylons
and stubbies to develop effective walking patterns. These
are prosthetic devices comprising sockets on simple end
devices that are short in stature to lower the centre of
gravity and ease balance. Once control, endurance and
function are reached, long articulating definitive prosthe-
ses can be tried.
Key point
Amputation is a lifelong, life-changing event. The
physiotherapist plays a key role in optimising a person’s
independence and their reintegration into normal life
experiences.
Weblinks
Amputee Running: www.amputee-running.com.
BACPAR: www.bacpar.org.uk
ISPO: www.ispo.org.uk
BAPO: www.bapo.org.uk
Scottish Physiotherapy Amputee Research Group
(SPARG)/National Centre for Training in Prosthetics and
Orthotics (NCTEPO), University of Strathclyde, Glasgow:
www.strath.ac.uk/prosthetics
Limbless Association: www.limbless-association.org
Limb Loss Information Centre:
www.limblossinformationcentre.com
471
 Tidy’s physiotherapy
FURTHER READING
BACPAR (British Association of
Chartered Physiotherapists in
Amputee Rehabilitation), 2009
Össur Guide to the use of the
Nintendo WiiFit in Lower Limb
Prosthetic Users. BACPAR, Leeds;
http://www.wiihabilitation.co.uk/
files/wii_fit_bro_uk_traffic_light_
version.pdf; and, Protocol for use of
the Nintendo WiiFIT balance board
with lower limb prosthetic users in
the physiotherapy department;
http://www.wiihabilitation.co.uk/
amputees.shtml, accessed October
2012.
BACPAR (British Association of
Chartered Physiotherapists in
Amputee Rehabilitation), 2008.
Guidelines for the Prevention of
Falls in Lower Limb Amputees.
BACPAR, Leeds; http://www.csp.org.
uk/sites/files/csp/secure/falls_
prevention_lowerlimb_amputees.
pdf; accessed October 2012.
BACPAR (British Association of
Chartered Physiotherapists in
Amputee Rehabilitation), 2010.
Toolbox of Outcome Measures.
BACPAR, Leeds; http://www.bacpar.
csp.org.uk/publications; members
only access.
BACPAR (British Association of
Chartered Physiotherapists in
Amputee Rehabilitation), 2010.
Risks to the contra-lateral foot of
unilateral lower limb amputees: A
therapit’s guide to identification and
management. BACPAR, Leeds;
http://www.bacpar.csp.org.uk/
publications; accessed October 2012.
Broomhead, P., Dawes, D., Hale, C.,
et al., 2003. Evidence Based Clinical
Guidelines for the Physiotherapy
Management of Adults with Lower
Limb Prostheses. Chartered Society
of Physiotherapy, London.
Broomhead, P., Dawes, D., Hale, C.,
et al., 2006. Clinical Guidelines for
the Pre and Post Operative
Physiotherapy Management of
Adults with Lower Limb
Amputation. Chartered Society of
Physiotherapy, London.
472
Butler, D.S., Lorimer Moseley, G., 2008.
Explain Pain. Noigroup
Publications, Australia.
Disability Information Trust, 1994.
Employment and the Workplace.
Disability Information Trust, Oxford.
Disability Information Trust, 1996.
Sport and Leisure – Equipment for
Disabled People. Disability
Information Trust, Oxford.
Disability Information Trust, 1998.
Powered Wheelchairs and Scooters
– A Practical Guide. Disability
Information Trust, Oxford.
Disability Information Trust, 1999.
Outdoor Transport. Disability
Information Trust, Oxford.
Divers, C., Scott, H., 2005. A
Physiotherapist’s Guide to
Prosthetic Knee Mechanisms and
Gait Training Principles. SPARG
(Scottish Physiotherapy Amputee
Research Group), Scotland.
Ham, R., Cotton, L., 1991. Limb
Amputation. Chapman & Hall,
London.
Ham, R., Barsby, P., Lumley, C., et al.,
1995. Amputee Rehabilitation – A
Handbook. Lumbley Associates,
York.
Howells, C., 2009. The Amputee Coach.
Global Publishing Group, Australia.
Johnson, S., Turner, A., Foster, M.,
2001. Occupational Therapy
and Physical Dysfunction:
Principles, Skills and Practice,
fifth ed. Churchill Livingstone,
Oxford.
Lusardi, M.M., Nielson, C.C., 2000.
Orthotic and Prosthetics in
Rehabilitation. Butterworth-
Heinemann, Oxford.
Mensch, E., Ellis, P.M., 1987. Physical
Therapy Management of Lower
Extremity Amputations. Heinemann
Physiotherapy, London.
PIRPAG (Physiotherapy Inter Regional
Prosthetic Audit Group), 2005.
Physiotherapy exercises for
lower limb amputation, http://
www.interactivecsp.org.uk/
uploads/documents/
PIRPAGAdviceSheetfor
Physiotherapists.pdf; members
only access.
PIRPAG (Physiotherapy Inter Regional
Prosthetic Audit Group), 2005.
Physiotherapy exercises for
lower limb amputation,
http://www.interactivecsp.org.uk/
uploads/documents/
PIRPAGExercisesTransfemoral.pdf;
members only access.
PIRPAG (Physiotherapy Inter Regional
Prosthetic Audit Group), 2005.
Physiotherapy exercises for
lower limb amputation,
http://www.interactivecsp.
org.uk/uploads/documents/
PIRPAGExercisesTranstibial.
pdf; members only access.
Rose, J., Gamble, J., 1992. Human
Walking, second ed. Williams &
Wilkins, Oswestry.
Smith, D.G., Michaels, J.W., Bowker,
J.H., 2004. Atlas of Amputations
and Limb Deficiencies: Surgical,
Prosthetic, and Rehabilitation
Principles, third ed. American
Academy of Orthopaedic Surgeons,
Rosemount, IL.
UNIPOD (United National Institute
for Prosthetics & Orthotics
Development). Limbless Statistics
Report – 2006/07. UNIPOD,
Salford; http://www.limbless-
statistics.org/, accessed October
2012.
Van de Ven, C., Engstrom, B., 1999.
Therapy for Amputees 1999, third
ed. Churchill Livingstone, London.
Whittle, M.W., 1991. Gait Analysis
– An Introduction. Butterworth-
Heinemann, Oxford.
Winchell, E., 1995. Coping with Limb
Loss: A Practical Guide to Living
with Amputation for you and your
Family. Avery Publishing Group,
New York.

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 Chapter
Massage
Joan M. Watt
INTRODUCTION
Massage is the starting point of the physiotherapy profes-
sion. Swedish massage was the basis for the strokes and
principles used by the first members of the Chartered
Society of Physiotherapists. There is evidence of massage
being used in many ancient civilisations. The word
massage may derive from the Arabic ‘mass’, meaning to
press, or the Greek word ‘massien’ meaning to knead.
Definition
Massage is an age-old process that involves stimulation
of the tissues by rhythmically applying both stretching
and pressure (Watt 1999). Holey and Cook (2003) define
therapeutic massage as ‘…the manipulation of the
soft tissues of the body by a trained therapist as a
component of a holistic therapeutic intervention.’
PREPARATION
Preparation encompasses the treatment room, couch, self,
patient and contact medium.
Treatment room
The treatment room needs to be kept at a comfortable
temperature to ensure the patient is not subjected to chills
or draughts. It must also afford the necessary privacy
without contravening the patient’s rights. There must be a
treatment couch, small arm table and chair.
21 
Couch
In the clinical setting most treatment couches/plinths can
have the height adjusted to suit the individual therapist.
To get a good height for performing massage, stand side-on
to the couch, rest your hand with fingers loosely flexed at
the metacarpal phalangeal joints and elbow not quite fully
extended. Adjust height of couch until you can comfort-
ably rest your hand as above. This takes time, trial and
error to gain the optimum position (Figure 21.1). The
couch should have a fresh clean cover and also a paper
couch roll, pillows, a face hole or face pillow, and blanket/
towels to cover the patient.
Self preparation
Stance
It is very important to ensure that your stance allows you
to reach all the parts to be massaged in a specific stroke
without having to keep altering position. Stand in lunge
position to perform long strokes, such as effleurage and
stroking (Figure 21.2). To reach across the patient assume
a similar position facing the couch (Figure 21.3). Do not
stand still – let your whole body go with the stroke and
always keep your pelvis tucked and knees slightly bent to
protect your back. Ensure your shoulders are relaxed, com-
fortable and not hunched.
Clothing
Clothing should be loose enough to allow unrestricted
movement whilst looking neat and professional. Hair
should not be allowed to come into contact with the
patient. If hair is long enough to touch the collar it should
be tied back.
475
 Tidy’s physiotherapy

Figure 21.1  Setting the plinth to the correct height.

Figure 21.2  Lunge stance.

Figure 21.3  Reaching the patient.

Hands 3. Push two, three and then four fingers between two
adjacent fingers of the other hand. Repeat in each
Hands are your most important tool when using massage.
space of both hands.
They must be clean, smooth and have skin that is well
4. Place palms together with fingers and thumbs in
nourished by using hand creams regularly. Nails should
contact and elbows bent at chest level. Slowly turn
be free from polish and cut short, so they do not show
hands to point fingers to ground. Return to start
above the fleshy finger pad. Only a very thin wedding ring
position.
can be worn, provided the patient does not experience any
5. Place the backs of the hands together, hold arms out
irritation from it. All other rings, bracelets, bangles and
straight and bend elbows up towards chin to flex
watch must be removed. It is also important to practise
wrists.
exercises to improve the ranges of movement of your
6. Clasp the hands with wrists crossed and elbows
hands. Hollis (2009) advocates full abduction/extension
straight. Bend the elbows to bring hands up to the
of the thumb to give a wide grasp of an octave span, and
chin and straighten the elbows out. Keep hands
full flexion and extension of the wrists or at least 80
firmly clasped at all times. Do not force – go only as
degrees of each movement, plus full pronation and supi-
far as is possible (Figure 21.4a–c).
nation of the radio-ulnar joints.

Exercises
1. Make a fist and then spread fingers and thumbs out
as far as possible; hold for 5–10 seconds.
2. Place the finger tips of one hand in contact with
finger tips of other and press so that thumbs and
little fingers are as widely spaced as possible.
Practice rhythm
Sit with a pillow on your knee with your hands open and
relaxed. Try to clap as rhythmically as possible. Repeat
with the ulnar borders of hands, clenched fists and ulnar
borders of fists (Figure 21.5).

476

Figure 21.4  (a–c) Pre-massage exercises.
Practice strokes
Sit with a pillow on your knees and grasp the outer edge
of pillow with lightly clenched hands. Alternately push
and pull with your hands (Figure 21.6).
Palpation
The sense of touch and palpation skills must be highly
developed in the person performing massage. It requires
practice to attune and improve our sense of touch and
therefore palpation skills. Start by feeling the differing
textures of various types of material. Sit with a pillow on
your knees and feel the pillow slip between fingers and
thumb, then do the same with a towel (Figure 21.7a).
Once you are happy you can easily tell one type of fabric
Massage Chapter 21
Figure 21.5  Practising your rhythm.
Figure 21.6  Practising strokes.
from another repeat the exercise with your eyes closed
(Figure 21.7b). Use your own body to identify anatomical
landmarks and accustom your hand to the feel of differing
tissues. Start by feeling the point of your elbow first with
thumb tip, then each finger separately and together, and
then with the palm of your hand. Repeat with each hand
in turn; close your eyes and focus on the message you
receive from your hands. Try the same routine on the calf,
shin, anterior aspect of the thigh, forearm, neck, shoulders
and abdomen.
477
 Tidy’s physiotherapy
A B
Figure 21.7  (a, b) Assessing textures.
Your sense of touch can be improved by many different
methods. Put a selection of different round objects of
various size and texture into a bag and then try to identify
each by touching only. As this becomes easier choose
smaller articles of more closely related textures and time
how long it takes to identify correctly.
It is also important to learn the depth of contact. Too
light can be uncomfortable and ticklish and is frequently
referred to as ‘skin polishing’. Too-heavy firm pressure may
well produce trauma and damage tissue. Practise depth
again on your own skin – try to move your hand across
your leg as lightly as possible and then increase depth until
you feel it is producing pain. Try out on a friend or col-
league and agree a score rate from, say, 1–5 of very light
to heavy. You make your mind up what depth/number you
are contacting then ask your model for their answer.
Always listen to what the model tells you and alter to get
to the score they think it is.
Patient preparation
It is important that the patient is fully informed of exactly
what the massage session will involve. Consent is dealt
with in ‘Legal aspects’ and must always be in place before
any massage starts.
478
It is vital to request the patient to remove the specific
pieces of clothing required to permit the treatment. Always
explain the reasons behind these requests. The patient’s
decency and modesty has to be respected at all times.
Neither the physiotherapist nor patient should ever feel
uncomfortable, threatened or embarrassed by the manipu-
lations being used. Always tell the patient exactly what you
are doing and why. Explain why strokes have to be taken
right up into the lymph drainage areas and make sure they
are content to have this done.
Draping or covering the patient has to be properly
carried out. Use shorts, towels of various sizes, towelling
robes and togas (Figure 21.8). Patient’s own clothing is
also very useful. Again, explain why you want the towel
tucked in and wherever possible get the patient to do this
for themselves.
Never remove any article of the patient’s clothing
without asking their specific permission to do so. Remem-
ber it is possible to apply some forms of massage through
one layer of clothing or over a thin cloth or towel.
Coupling media
Many and varied products are used as coupling media in
massage. Massage oils, creams, gels and powders, and

A Never apply any heating agent/cream when you are
B massage without such consent can be construed as assault.
C
Figure 21.8  (a–c) Covering the patient.
aromatherapy products are readily available. The first and
most important step is to ensure that the lubricant selected
is acceptable to both patient and masseur, and there are
no contraindications to its use.
It is essential that there is full information on all the
contents of the chosen product. This is vital if the recipient
or masseur has any allergies. Many massage oils/creams
use nut oils as a base and, obviously, this should never be
applied in cases of nut allergy. Very hairy skin can be irri-
tated and damaged by the use of powder or too little
lubricant during massage. Powder should never be applied
to hot sweaty skin as it clogs pores and tends to form hard
lumps on the surface.
Massage Chapter 21
Ice massage can be extremely useful but great care must
be taken to ensure the skin is not damaged by the effect
of the ice. Always ensure the ice is kept moving, regularly
check skin colour and reaction. Stop if the patient reports
feeling uncomfortable or cooling too fast.
Apply oils directly to your hands and do not use too
much. Always make sure the whole area to be treated is
clean before starting and also clean thoroughly at the end
of massage.
Water alone or soapy water can be used with good effect
as a lubricant and the addition of a small amount of oil
can be beneficial when dealing with dry, scaly skin.
treating any area where there has been tissue damage and
healing. A hot cream may produce too much superficial
increase in skin temperature and create further damage.
LEGAL ASPECTS
It is mandatory to acknowledge and implement all perti-
nent legal requirements before, during and after using
massage. The practitioner must explain the reasons for
applying massage and explain exactly what is involved.
Written informed consent must be obtained – to apply
Throughout the whole treatment both patient and physi-
otherapist must be totally comfortable and at ease with
the methodology. Keep inquiring if the patient is happy
and content with the proceedings.
All child protection, chaperone and local laws must be
obeyed. Remember to keep accurate, legible, dated and
signed treatment notes. Don’t just write ‘massage’: give a
short description of techniques used and list outcomes.
CONTRAINDICATIONS
In some conditions massage can exacerbate problems and
can be dangerous. Always have a diagnosis, carry out an
assessment and be clear on the aims of the treatment.
1. Skin infections of viral, fungal or bacterial origin are
contraindications to massage. Any type of skin
infection in the area to be massaged or involving the
hands of the physiotherapist would preclude the
application of massage.
2. Open wounds should not be massaged. Apart from
being painful, massage can damage the healing
tissue and restart bleeding and may cause infection.
3. Circulatory problems can be adversely affected
by massage which increases blood flow and
manipulates the blood vessels. Bleeding disorders,
such as haemophilia, arteriosclerosis, haemorrhage,
thrombosis and artificial blood vessels, are all
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 Tidy’s physiotherapy

contraindications to massage. Remember deep vein

thrombosis is a total contraindication to massage.
4. Recent injury, if massaged too early in the healing
process, will cause further damage. Massage at that
stage will cause trauma to the fragile healing tissue
leading to delay in repair, further bleeding and
resultant excess scar tissue. It is recommended that
massage should not be started until 48 hours after
injury. Always ensure bleeding has stopped. Proceed
with great care and use very gentle strokes initially.
5. Tumours can be mechanically stimulated by massage
which speeds up metabolism and so spreads the
tumour. Do not massage directly over or close to a
tumour. Remember massage can be very effective
and prove an invaluable aid to cancer victims and in
palliative care. A
6. Acute inflammation is contraindicated for massage
as the inflammatory process can be increased by the
effects produced.
7. Myositis ossificans should not be massaged directly.
This can produce increased formation of bony cells
and further damage the soft tissues surrounding the
site. Vigorous deep massage has been known to
separate small bony particles from the site of
ossification.
8. Diabetes – although not a total contraindication to
massage, great care must be used when treating
diabetics with massage. It is usual for the peripheral
circulation to be affected in diabetes and as a result
blood vessels and skin can be easily damaged. Apply
massage with great care.
9. Alteration of skin sensation can be a
B
contraindication to the use of massage.
Massage may be used in certain circumstances, provided Figure 21.9  (a, b) Stroking.
the experienced practitioner has an accurate diagnosis and
knows the extent and reason for the changes. Loss of sensa-
tion, heightened sensation, presence of tingling or neuro- Stroking
logical skin alteration all contraindicate massage.
This is, as the name suggests, a stroking movement, tradi-
tionally performed from distal to proximal in the direction
of the lymph drainage (Figure 21.9a). It can also be per-
TECHNIQUES formed in the opposite direction or in a cross over method.
This manipulation can be applied using pads of fingers,
thumbs, one, two or alternate hands (Figure 21.9b). A
Massage manipulations are grouped into various head- specific type of stroking is ‘Thousand Hands’, as first
ings. The three listed are the main components of basic described by Hollis (2009). In this case, one hand is used
massage. to perform a short stroke and then the second hand per-
1. Stroking manipulations. forms the same movement overlapping the first. This is a
2. Pressure or petrissage manipulations. fairly light touch, but must not be so light as to irritate or
3. Percussive or tapotement manipulations. tickle, and can be applied in fast or slow strokes.

Stroking manipulations Effects of stroking

• Gets the patient used to your touch.
There are two strokes in this group: • Allows assessment of the state of the skin and tissues
• stroking and of the area to be treated.
• effleurage. • Improves sensory analgesia.

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A The listed contraindications apply for stroking and
B distal to proximal (Figure 21.11a,b). Whole hand, one,
Figure 21.10  (a, b) Effleurage.
• Slow stroking will relax and sedate and decrease
muscle tone.
• Faster strokes will stimulate superficial blood flow,
accelerate lymph drainage.
• Used at start and end of session.
Effleurage
The meaning of this word is to stroke; in massage it is a
deeper form of stroking (Figure 21.10a). As such, it can be
applied as described for stroking and also be reinforced
with one hand over the other, or using lightly clenched fist
(Figure 21.10b) or forearm. Because this manipulation
goes deeper it can be graded. Grade 1 is sufficient to influ-
ence flow in superficial vessels; grade 2 affects deeper
vessels; and grade 3 applies to reinforced effleurage, with
one hand on top of the other. Effleurage can be applied
in the direction of the lymph glands, or opposite, in
all sorts of patterns from a Figure 7 or 8, to a circular or
T shape.
Massage Chapter 21
Effects of effleurage
• Assists lymphatic and venous return.
• Assists interchange of tissue fluid.
• Assists removal of waste product and chemical
irritants.
• Passively stretches muscle fibres.
• Restores mobility at tissue interfaces.
• Light strokes decrease muscle tone.
• Deep strokes increase muscle tone.
• Used at start, end and inbetween other
manipulations.
Clinical note
effleurage. Also ensure enough pressure and contact to
prevent tickly sensations and apply sufficient lubricant to
allow smooth movement over the skin at all depths.
Pressure manipulations or
petrissage
The petrissage group is made up of five categories: knead-
ing, picking up, wringing, rolling and shaking.
Kneading
The tissues are compressed against the underlying struc-
tures during this stroke. The kneading action is performed
in a circular movement either from proximal to distal or
both or alternate, finger and thumb tips, or finger and
thumb pads may be used to perform this manipulation.
The stroke can also be superimposed or reinforced by
placing one hand or other fingers on top of the contact.
The action is to perform a circular movement with pres-
sure on the upward part for about 25% of the circumfer-
ence. Contact must be maintained for the rest of the circle
and only be lifted to move on to the next circle.
Kneading is graded into three grades: grade 1 is suffi-
cient to influence superficial vessels and compress super-
ficial tissues on underlying structures; grade 2 affects
deeper tissue drainage and will compress deep tissue on
underlying structures; and grade 3 is applied to superim-
posed or reinforced strokes and may be as much as can be
tolerated by the patient without producing tissue damage.
Effects of kneading
• Stimulates venous and lymphatic flow.
• Increases mobility of fibrous tissues.
• Helps interchange of tissue fluids.
• Helps prepare soft tissue for exercise.
• Helps removal of waste products.
• Increases length and strength of connective tissues.
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 Tidy’s physiotherapy

Start here

B Finish here
Figure 21.11  (a, b) Kneading.

482

A A
B B
Figure 21.12  Picking up: single-handed C. (a) Hand position;
(b) on the patient.
• Provokes somato-visceral reflex effects.
• Restores mobility between tissue interfaces.
Clinical note
The listed contraindications above apply to kneading. Be
careful not to compress too heavily. Take care not to nip
tissue by squeezing too hard.
Picking up
The tissues are compressed against underlying structures,
then ‘picked up’, lifted, squeezed and released. The
manipulation can be single-handed C-shape (Figure
21.12a), double-handed alternate C-shape, single-handed
V-shape (Figure 21.13) or double-handed V-shape. For
C-shape, the thumb is held away from the palm so that
the web between it and the first finger form a C-shape
(Figure 21.12b). V-shape is when the web forms a
letter V (Fig 21.13).
Grading for picking up is the same as kneading with
grade 3 only being used in the double-handed manipula-
tion and will only be tolerated over very muscular areas.
Massage Chapter 21
Figure 21.13  Picking up: single-handed V. (a) Hand position;
(b) on the patient.
Effects of picking up
• Exactly the same as for kneading.
• Particularly good for mobilising soft tissues.
• Use after effleurage and kneading.
Clinical note
The contraindications as listed above apply to picking up.
Be sure there is no recent soft tissue trauma. Be aware
that if skin contact is lost during this manipulation a
pinching action will result.
Wringing
In wringing the tissues are compressed against underlying
structures, then one hand pulls towards the physiothera-
pist and the other hand pushes away. Fingers and thumb
can be used in wringing with the tissues being compressed
between them. The tissue is then lifted and pulled towards
you with one hand and pushed away from you with the
other. Full hands are also used in this stroke (Figure
21.14). There are only two grades for wringing: 1 and 2.
Grade 1 is usually applied to finger strokes only with grade
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 Tidy’s physiotherapy
Figure 21.14  Wringing.
Figure 21.15  Rolling.
2 using the whole hand. There is no grade 3 as it would
be too painful to tolerate.
Effects of wringing
These are as stated for kneading. Wringing is particularly
good for separating superficial and deep adherent tissue.
Clinical note
The usual contraindications apply for wringing. Be aware
of tissue damage if used on recently injured tissue.
Grasping tissue too tightly will produce a nipping effect.
Rolling
In this manipulation both hands are used. Contact is
made with both palms and the thumbs are held away from
the fingers; the tips of the thumbs are close to, or touch,
each other (Figure 21.15). The fingers pull the tissue
towards the thumbs and then the thumbs squeeze and lift
to push the tissue away.
There are two types of rolling – skin rolling and muscle
rolling. In muscle rolling, the roll action is not so marked
484
Figure 21.16  Shaking.
and the action is more push with fingers and pull back
with the thumbs. Skin rolling is grade 1 and muscle rolling
is grade 2. Again, there is no grade 3 because it would be
too painful.
Effects of rolling
• These are as stated for kneading.
• Rolling also mobilises scar tissue.
• When performed slowly it has a stretch effect on the
tissues being manipulated.
Clinical note
The usual contraindications apply for rolling. Take care
not to nip tissues on applying action. Do not be too
vigorous when working with recent scar tissue.
Shaking
In this manipulation muscle or more superficial tissue can
be shaken from side to side. The tip of the thumb and tips
of one or more fingers are used when treating small areas.
The full length of thumb and all fingers are used in larger
areas (Figure 21.16). In a very large area, such as the but-
tocks or thighs, the whole flat hand can be placed on the
area and after applying gentle compression shaken. In the
final type of shaking – whole limb shaking – the leg or
arm is lifted, gently supported and then shaken. Grade 1
shaking is used to describe thumb and finger tip shaking;
grade 2 applies to full thumb and fingers and also to flat
hand; grade 3 is whole limb shaking.
Effects of shaking
• This manipulation produces a feeling of invigoration
and stimulation.
• Increases tissue mobility.
• Assists in breaking down tissue adhesions.
• Stimulates lymphatic and venous flow.
• Helps prepare soft tissues for stretch and exercise.

Figure 21.17  Hacking.
Clinical note
The usual contraindications apply to shaking with specific
care being taken to ensure the tissues are not nipped
when using fingers and thumb. It is important in whole
limb shaking that the patient is relaxed and there is no
‘kick back’ produced in any joint or any feeling of strain
by the patient.
Percussion or tapotement
manipulations
In this category of massage strokes there are five main
types: hacking, clapping, beating, pounding and vibra-
tion. In some cases, the last mentioned stroke could be
applied to the petrissage group but that tends to be in the
more specific massage for sport and not the general
concept.
Hacking
To perform this manipulation the arms are held abducted
with the elbows bent. The area to be massaged is then hit
by the medial border of the hands and/or fingers (Figure
21.17). The action is produced by pronation and supina-
tion of the radio-ulnar joints. It is important that the
practitioner’s shoulders and hands are relaxed and not
held in any tension. The rhythm of all percussion strokes
should be practised to ensure it is consistent.
Grade 1 uses only the medial borders of the fingers;
grade 2 uses medial borders of hands and fingers; grade 3
uses the medial borders of hands and fingers more deeply
and slowly.
Effects of hacking
• Stimulates local circulation.
• Stimulates muscle tone.
• Gives generalised feeling of stimulation.
Massage Chapter 21
Figure 21.18  Clapping.
• Provokes muscle and tendon reflexes.
• Light strokes effect superficial tissue.
• Deeper strokes aid the evacuation of the lungs.
Clinical note
All the usual contraindications apply to hacking. When
using deep technique it is good practice to cover the
area with a thin cloth to prevent any skin irritation.
Clapping
To perform this stroke the hands are held loosely cupped
and the area is struck by the palmar aspect of the hands
and fingers (Figure 21.18). The action is produced by alter-
nately flexing and extending the wrist joints.
Grade 1 clapping is very superficial, often called skin
clapping. This is used at a fairly fast pace with minimal
contact. Grade 2 is deeper, slower and firmer, and grade 3
clapping is very firm and may involve elbow, as well as
wrist, action.
Effects of clapping
These are the same as listed for hacking with the exception
of provoking tendon or muscle reflex.
Clinical note
All the usual contraindications apply to clapping. Always
ensure the hands are relaxed or the patient will find the
contact produces pain. In grade 3 clapping, cover the
area with a light cloth.
Beating
This form of tapotement involves the use of lightly
clenched fists to hit the area. The action involved is wrist
485
 Tidy’s physiotherapy

flexion and extension with the finger/palmar area making

contact with the treatment area (Figure 21.19).
Grade 1 beating is performed at a fast rate, with
fairly light contact. Grade 2 is slower with firmer contact
and grade 3 is very deep and the rate can be varied as
required.

Effects of beating
The effects are identical to clapping.

Clinical note

The usual contraindications apply to beating. Again,

ensure that hands are relaxed during the stroke. Always Figure 21.19  Beating.
make sure you cover tissue with light cloth with grade 3.

Pounding
In this stroke the hands are held in lightly clasped fists
with the thumbs resting against the first fingers. The action
is to pronate and supinate the radio-ulnar joints and make
contact with the patient using the ulnar border of the hand
(Figure 21.20).
Grade 1 of this stroke applies to fast rate, light contact.
Grade 2 is used for slower rate with firmer contact and
grade 3 is deeper, with varying rates.

Effects of pounding
These are exactly the same as listed for clapping. Figure 21.20  Pounding.

Clinical note

The same precautions should be applied as for clapping.

Vibrations
In this manipulation the tissues are pressed and moved up
and down, or away from and towards the manipulator and
then released. At the same time small oscillations of the
whole arm produce a trembling effect. A single hand or
both hands (Figure 21.21) may be used, and hands should
be held slightly in flexion.
Grade 1 applies to light rapid movements. Grade 2 is
firmer and slower with more tissue movement, and grade Figure 21.21  Vibrations.
3 is as firm a pressure as can be tolerated and in a very
slow action.
Clinical note
Effects of vibrations
• Stimulates muscle tone. The usual contraindications apply to vibrations. Hands
• Stimulates local circulation. must make firm enough contact to not produce ticklish
• Provides feeling of well-being. sensation.
• Aids peristalsis.

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 Massage Chapter 21

OTHER TECHNIQUES

Massage is still evolving and, as a result, there are newer

types of manipulations being added and with the increase
in good scientific research we are able to understand what
these can do. We shall consider a few here, but this is in
no way a comprehensive list. As long as massage is a well-
used, practised and evaluated skill it will develop and new
ideas will be added.
In this section we will look at myofascial release, fric-
tions, trigger pointing and acupressure.

Figure 21.22  Myofascial spread.

Myofascial release
As the name suggests, this type of manipulation is used to
produce change in the myofascia, both superficial and
deep. Myofascia is continuous throughout the body and
is made up of collagen fibres. Superficial fascia underlies
the skin and deep fascia covers, separates and protects
skeletal muscle. The functions of the fascia are to form,
support, provide boundaries, guide, mould, compartmen-
talise and control.
Problems associated with the fascia which respond to
the myofascial massage manipulations are:
• adhesion formation;
• restricted or prevented movement;
• alterations to the internal muscle structure;
• fibrositis;
• tissue contraction and scarring.
Strokes used in myofascial release are myofascial spread,
fascial lift and roll, and myofascial mobilisation.
Clinical note
All the general contraindications apply to the use of
myofascial techniques. Caution should be used when
dealing with flaccid paralysis, lax or unstable joints.
Beware some advanced arthritic joints are held by fascial
splinting.
Fascial lift and roll
This technique is very similar to skin and muscle rolling
but is aimed at the fascia. Both hands are placed over the
area, the tissue is lifted until a very slight resistance is felt
below the skin level. The tissue is then lifted slowly and
pressed by the thumbs towards the fingers (Figure 21.23).
Grade 1 only applies as only used on superficial fascia.

Myofascial spread Effects of fascial lift and roll

This manipulation is basically a stretch technique. Finger
tips or hands in a line or crossed can be used. The hands/
fingers are laid on the tissue and pressed in until a slight
resistance is felt. The hands are then drawn apart evenly
until the tissue will go no further. This position is
held until the resistance gives and the hands slide further
apart (Figure 21.22). The movement is slow, steady and
sustained.
Grade 1 applies to release of superficial fascia and grade
2 deals with deep fascia.
Effects of myofascial spread
• Makes fascia more fluid.
• Releases collagen bonds.
• Lengthens fascial layers.
• Restores mobility.
• Decreases effects of adhesions and scars.
• Releases adherent areas in the superficial fascia.
Clinical note
Precautions are exactly as for myofascial spread. Never
force the tissue.
Myofascial mobilisation
To perform this stroke the fingers, knuckles, palms or
forearm are placed on the surface, pressure is applied and
the myofascia is moved against the underlying structures.
The action can be forwards and backwards or circular in
pattern (Figure 21.24).
Grade 1 is light and is used for the superficial fascia.
Grade 2 is deeper and mobilises the deeper fascia.

487
 Tidy’s physiotherapy

Clinical note

Precautions are as for myofascial spread. Myofascial

mobilisation should not produce pain.

Frictions
This massage technique was developed by Dr James Cyriax
to treat soft tissue lesions (Cyriax 1993). This is a localised
technique applied at the injury point and aims to give a
A stretching across the fibres to separate them and restore
mobility.
To perform this stroke the finger tips or thumbs are
applied either alone or reinforced by the adjacent finger.
The action is then to move across the tissue (transverse
friction (Fig 21.25) ) or perform a circular pattern (circular
friction).
Grade 1 does not apply to this technique as friction is
aimed at deeper structures; grade 2 is sufficient to affect
deep tissue and cause compression; grade 3 applies to
reinforced and most transverse frictions, and may produce
pain before causing numbing.

Effects of frictions
B
• Restores tissue mobility.
• Stimulates local circulation.
• Aids the resolution of inflammation.
Figure 21.23  (a, b) Fascial lift and roll. • Reduces pain as a counter irritant effect.
• Stretches fibrous tissue.

Clinical note

All the usual contraindications apply. Friction must be

given to exact site of damage. Skin must move with the
finger/thumb tips. Use little, or no, lubricant. Warn
patient treatment can cause pain until numbing takes
place – usually about two minutes. Always apply within
the patient’s tolerance.

Trigger pointing and acupressure

Figure 21.24  Myofascial mobilisation.
Effects of myofascial mobilisation
• Frees myofascia which is adhering to itself or
underlying tissues.
• Re-establishes the ability of tissues to slide freely
over each other.
Trigger points in the myofascia were first identified by
Travell and Simons (1992). These points are bands within
a muscle which have become ischaemic and fibrous
because they have been held in excess spasm or tone for
some time. The cause can be postural or mechanical and
may be affected by metabolic, nutritional or other factors.
The trigger points are easily identified by palpation.
Pressure produces pain and this can be in the particular
pattern of referral as described by Travell and Simons.

488

Figure 21.25  Deep transverse friction to the gastrocnemius
musculotendinous junction.
Figure 21.26  Trigger pointing.
Types of trigger point
There are various types of trigger point and it is important
to address all when treating:
• active – produces pain at rest;
• latent – only pain on palpation;
• primary – response to trauma, acute or chronic
overload;
• key – activates or neutralises satellites;
• satellite – activated by key, situated in area of referral
or antagonist or synergist;
• general – near centre of muscle fibre;
• attachment – in tendon or aponeurosis.
To apply trigger pointing technique a deep stroking is
performed by the tips of finger or thumbs. Direct pressure
may be applied to the specific point by thumb, finger tip
or elbow (Figure 21.26). Hold for 8–12 seconds, treat the
area of referred pain and always stretch after trigger point-
ing. When full range has been restored the trigger point
will no longer be active.
Massage Chapter 21
There is no grade 1. Grade 2 applies to the stroking
technique and grade 3 is as much as the patient can
tolerate.
Effects of trigger pointing
• Gives pain relief.
• Reduces muscle spasm.
• Helps restore normal muscle tone.
• Allows full stretch of tissue.
Clinical note
The usual contraindications apply to trigger pointing. It
must always be applied within the patient’s tolerance.
Acupressure
Acupressure is very similar to trigger pointing, where direct
pressure is applied. In this technique the pressure is
applied to the points on the acupuncture meridian lines
with the aim of producing effects on the tissue without
using needles.
Effects of acupressure
• Pain relief by release of endorphins.
• Stimulates local circulation.
• Stimulates lymphatic flow.
Clinical note
Contraindications as mentioned before apply to
acupressure. It should not be used on patients with heart
disease or visceral conditions. The therapist must have
full knowledge of acupressure points and an
understanding of energy points and the philosophy
behind the oriental belief.
SPECIFIC USAGE OF MASSAGE
Tension headaches
Tension headaches respond well to treatment with
massage techniques. Start off with effleurage to identify
particular tension spots and accustom them to touch.
Address the mid-scapular, trapezius and levator scapulae
areas with trigger pointing (Figure 21.27a), then treat the
base of the skull with pointing and gentle thumb/finger
circular kneading (Figure 21.27b). The length of time
489
 Tidy’s physiotherapy

A B

C D

E Figure 21.27  (a–e) Management of tension headaches with

massage techniques.

A B

Figure 21.28  (a, b) Frictions for lateral epicondylitis (tennis elbow).

490

A B
Figure 21.29  (a, b) Frictions for Achilles tendonitis.
for relaxation to be felt will vary from 4–5 minutes to 10
minutes. When the tension releases return to the use of
effleurage for the whole upper posterior shoulder area and
then turn the patient into supine. In this position start
with the two acupressure areas immediately above the
inner eyebrows (Figure 21.27c), trigger for 20 seconds on,
then 20 seconds off. Four times is usually sufficient. Then,
move to the two points at the side of the temple (Figure
21.27d) and repeat the same routine; finally, go to the
point in the posterior web of each thumb (Figure 21.27e)
and use the 20 seconds on and off again for four repeti-
tions. It is also good to teach the patient to administer
these trigger point routines on themselves.
Specific frictions for tennis elbow
Identify the centre of the pain by asking the patient to
extend the wrist against resistance. Once located, start with
circular friction to accustom the patient to the touch and
gradually deepen (Figure 21.28a). Then, change to trans-
verse friction (Figure 21.28b), warn the patient they will
experience pain and ensure you are working within their
tolerance. After a maximum of two minutes the spot
should become numb and the patient may well say the
pain has gone. Teach them home-stretching exercises
and explain that ice massage may also be of some help.
The treatment can be repeated as often as the patient can
tolerate but the deep transverse friction may preclude
further intervention for 3–4 days.
Friction of tendo-Achilles
Frictions are used very successfully for the treatment of
Achilles tendonitis. Start with the foot resting over a
rolled-up towel (Figure 21.29a). Isolate the tendon and
ensure you are clear of the bursa – use a circular pattern
alternating between finger and thumb. Increase depth as
the patient can tolerate, but, again, always work within the
patient’s tolerance (Figure 21.29b). Follow with full-range
Massage Chapter 21
passive stretch, then assisted stretch and finally into active
stretch and eccentric exercises.
Massage for lymphoedema
Reduction of post-mastectomy lymphoedema can be
helped by the careful administration of massage. The
patient should be seated with the arm in elevation (Figure
21.30a). Start by clearing the distal areas first with short,
light effleurage strokes (Figure 21.30b). As you begin to
approach the axilla the patient may well tense up as this
area can be extremely tender and sensitive. Explain what
you are doing and start at the posterior aspect of the upper
arm again, using short, no greater than grade 1, effleurage
(Figure 21.30c). Slowly work to the lateral, anterior and,
finally, medial aspects. Finish with full-arm effleurage
deeper distally and easing as you near the drainage areas
(Figure 21.30d).
The next steps in massage – how  
to build on and enhance basic
massage skills
More and more the title massage is being changed and the
skills described are being referred to as soft tissue therapy.
This new title encompasses many additional modalities
such as soft tissue release, deep tissue massage, connective
tissue massage, aromatherapy, Shiatsu and the Bowen
technique. In specifically-applied massage, such as sports
massage, techniques including proprioceptive neuromus-
cular facilitation (PNF) and muscle energy (MET), neu-
romuscular technique and strain–counter strain are
frequently taught. Some of those names refer to the same
or very similar applications and this makes it difficult to
investigate and get useful research results. There are,
however, an increasing number of good research studies
available and the use of all massage techniques is in­­
creasing, despite it being a one-to-one, time-consuming
treatment.
491
 Tidy’s physiotherapy
A B
C D
Figure 21.30  (a–d) Massage for lymphoedema.
FINAL THOUGHTS
• We still do not fully or scientifically understand the
total effects of touch.
• Be prepared and aware that by releasing, relaxing
and easing soft tissue, the practitioner may
also cause emotional release. It is not unusual
for patients to cry or feel very drowsy after
treatment.
• Always have permission to touch and a signed
informed consent form. Remember, failure to do so
can be construed as assault or even battery.
• Explain exactly which areas you will touch and
why.
492
• Never proceed if you or the patient feel
uncomfortable or embarrassed with the procedure.
• Respect the patient’s privacy and expose only the
areas required. Use any draping so that your hands
cannot disappear under it during the performance of
any techniques.
• Request the patient’s permission to remove or undo
any clothing.
• Get the patient to tuck in towels or other drapes
themselves.
• Remember to respect all legalities, including child
protection and chaperonage.
• Regularly ask if the patient is comfortable and happy
with the massage.
• Protect your own back and hands.

FURTHER READING
Andrade, C.-K., Clifford, P., 2000.
Outcome Based Massage. Lippincott
Williams and Wilkins, Philadelphia.
Benjamin, B., Sohnen-Moe, C., 2004.
The Ethics of Touch. Sohnen-Moe
Associates, Tucson.
Dryden, T., Moyer, C.A., 2012. Massage
Therapy: Integrated Research and
REFERENCES
Cyriax, J., 1993. Text Book of
Orthopaedic Medicine, Vol. 2.
Balliere and Tindall,
London.
Holey, E., Cook, E., 2003. Evidence
Based Therapeutic Massage.
Practice. Human Kinetics,
Champaign, IL.
Jarmey, C., Tindall, J., 2006.
Acupressure for Common Ailments.
Gaia Books, London.
Neil-Asher, S., 2005. The Concise Book
of Trigger Points. Lotus Publishing,
Chichester.
Churchill Livingstone,
Edinburgh.
Hollis, M., Jones, E., 2009. Massage
for Therapists: A Guide to Soft
Tissue Therapy. Wiley-Blackwell,
Oxford.
Massage Chapter 21
Hollis, M., Jones, E., 2009. Massage for
Therapists: A Guide to Soft Tissue
Therapy, third ed. Wiley-Blackwell,
Oxford.
Johnson, J., 2009. Soft Tissue Release.
Human Kinetics, Champaign, IL.
Johnson, J., 2011. Deep Tissue Massage.
Human Kinetics, Champaign, IL.
Travell, J., Simons, D., 1992.
Myofascial Pain and Dysfunction,
Lippincott Williams and Wilkins,
Philadelphia.
Watt, J., 1999. Massage for Sport.
Crowood Press, Ramsbury.
493
 Chapter 22 
An introduction to fractures
Helen Alsop and the Executive Committee of the Association of
Orthopaedic Chartered Physiotherapists

This chapter looks at some basic facts and concepts about
fractures but should not be seen as a definitive guide
to fracture management. Suggested further reading is
included at the end of the chapter.
DEFINITION AND CLASSIFICATIONS
Definition
blow could give a transverse or oblique fracture depending
on the angle of the force and whether the limb is fixed or
moving at the time of the trauma. Longitudinal forces tend
to result in compression or crush fractures. In some cases
there are a number of fragments of bone and this is termed
a ‘comminuted’ fracture (not to be confused with ‘com-
pound’). Loose fragments of bone are known as ‘butterfly
fragments’.
A greenstick fracture is a type of fracture sustained by
young children whose bones are still relatively malleable;
therefore, fractures are more likely to present as an

A fracture is an interruption in the continuity of bone.

The terms fracture and break mean the same thing in
medicine. The symbol # (hash) represents a fracture.

Classification of fractures
There are numerous different ways of classifying fractures
and this will vary depending on country, hospital or con-
sultant preference. Although it is helpful to categorise
common fracture types and mechanisms, any bone may
break in a variety of ways, so no two fractures will be
exactly alike. Obviously, the type of fracture will affect the
initial management and treatment.
Fractures may be classified as open or closed (Figure
22.1). Open or compound types of fracture occur when the
bone-end or some other object has pierced the skin. These
fractures are an additional cause for concern because of
the possibility of the introduction of microorganisms,
leading to bone infection (osteomyelitis). With closed
fractures the skin remains intact. Another common clas-
A B
sification includes displaced or un-displaced.
Figure 22.2 shows some further classifications. Spiral Figure 22.1  (a) Closed fracture. (b) Open or compound
fractures commonly occur from a twisting injury. A direct fracture. (Adapted from Dandy and Edwards 1998, with permission.)

495
 Tidy’s physiotherapy
A B C D
F G
Figure 22.2  Classification: (a) spiral; (b) transverse; (c) oblique; (d) compression; (e) comminuted; (f) greenstick;
(g) pathological; (h) avulsion; (i) impacted.
incomplete fracture – a greenstick fracture. (The analogy
is attempting to break a green twig, which will bend and
split but not snap.) Avulsion fractures occur when a bit of
bone is pulled off owing to its attachment to soft tissues
(e.g. ligaments). Impacted fractures are generally com-
pressed and therefore more stable.
THE CAUSES OF FRACTURES
Trauma
Most fractures are a result of some form of injury. This
might be a direct blow, a fall from a height or a weight
falling onto a part of the body. Other fractures may be
caused by indirect trauma, such as falling on an out-
stretched hand leading to the transmission of force up the
arm causing a fracture of the clavicle. Twisting forces may
result in fractures of the tibia and fibula, for example
during soccer or skiing when the weight of the body
rotates on a fixed foot. Stress or fatigue fractures are caused
496
E
H I
by repeated minor trauma, which can occur after walking
or running long distances, and often affect the foot
metatarsals.
Pathological fractures
These occur as the result of a disease that weakens the
composition of the bone itself, making it liable to fracture
as the result of a relatively trivial injury. There are a number
of such diseases but those most commonly seen clinically
are osteoporosis, Paget’s disease, carcinoma, osteomyelitis
or osteogenesis imperfecta (brittle bone disease).
CLINICAL FEATURES OF FRACTURES
Clinical features vary depending on the cause and nature
of the injury, and range from unconsciousness to the
patient being able to use the limb, although complaining
of pain – such as following fatigue fractures and some
impacted or crack fractures. Most will be diagnosed by

X-ray. Some fractures, for example fractures of the scaphoid
bone, are sometimes not detected upon initial X-ray and
can be misdiagnosed as wrist sprain. The clinical features
of fractures are summarised below.
Pain
This may be immediate from the local inflammatory reac-
tion and trauma, but the cause may not be obvious in
some cases. There will be marked tenderness around the
site of the fracture. Once reduced, a fracture is remarkably
painless.
Deformity
This is noticeable when there is displacement of the bone
fragments. Some fractures exhibit classical deformities, for
example the ‘dinner fork’ deformity which occurs follow-
ing a Colles’ fracture of the distal radius, caused by dis-
placement of the distal fragment; and also shortening of
the leg with a fractured neck of femur.
Oedema
This is localised immediately after the injury and becomes
more extensive with time. It may be necessary to apply a
temporary cast or splint and then reapply the plaster once
the swelling has subsided.
Muscle spasm
Muscle spasm is an attempt by the body to stop things
from moving. It often affects powerful muscle groups, such
as the quadriceps, and may cause displacement or overrid-
ing of the bone ends. Traction may be needed to counter-
act this.
Abnormal movement/crepitus
There may be grating between the broken ends of the
bone. Do not deliberately attempt to elicit this, though,
because that might result in further damage.
Loss of function
This may be complete following severe fractures but
some activity may be possible when the injury is less
severe, such as stress, impacted or crack fractures. Some-
times normal function can be regained very quickly with
appropriate assessment, advice and treatment, whereas in
other cases there are a number of problems for which
more intensive treatment may be required. Modern ortho-
paedics is now geared towards early mobilisation with
minimal surgical trauma, and physiotherapy needs to
complement this.
An introduction to fractures Chapter 22
Shock
Hypovolaemic shock is a possibility following fractures.
A fractured shaft of femur may haemorrhage as much
as three pints (1.7 litres).
Limitation of joint movement
Joint mobility can be affected by many factors: adhesion
formation, tight muscles, pain, spasm, fear, mechanical
obstruction or swelling. Movement may also be limited
because of weak muscles, in which case it will be possible
to move the joint passively through total range. If the
fracture involves the articular surface of the joint this may
also cause limitation of movement and future cartilage
degeneration. For this reason, certain fractures are now
treated aggressively with almost immediate movement
(aggressive in this context meaning soon, not rough).
Muscle atrophy
There will be a loss of strength in disused muscle groups.
FRACTURE HEALING
Healing of compact bone
Bone has the incredible ability to replace itself with new
bone, not scar tissue. Healing starts within seconds of a
fracture being sustained and will still be ongoing years
later – this makes ascribing a healing timescale difficult.
Wolff’s law states that bone responds to the stresses
that are imposed upon it by rearranging its internal archi-
tecture to best withstand the stresses. In other words, bone
is laid down where it is needed and absorbed where it is
not. It is important to understand this concept when
dealing with people who have sustained fractures. Bone
is a living tissue, not the brittle, chalky specimens that
students may be familiar with. It is continually in a
dynamic equilibrium of growth and reabsorption. Figure
22.3 shows the process of fracture healing in compact
bone taken through five stages.
Haematoma
As a result of the tearing of blood vessels within seconds
of the injury, a haematoma forms at the fracture site. Very
small portions of bone immediately adjacent to the frac-
ture die and are gradually absorbed.
Periosteal and endosteal proliferation
There is a proliferation of cells from the deep surface of
the periosteum adjacent to the fracture site. These cells are
precursors of the osteoblasts and form around each
497
 Tidy’s physiotherapy
A
B
C good and it is difficult to see the fracture site on a radio-
D cellous bone has a greater area of contact between the
E
Figure 22.3  Fracture healing: (a) haematoma; (b) periosteal
and endosteal proliferation; (c) callus formation;
(d) consolidation; (e) remodelling.
fragment of bone. At the same time cells proliferate from
the endosteum in each fragment and this tissue gradually
forms a bridge between the bone ends. During this stage
the haematoma is gradually reabsorbed.
Callus formation
The proliferating cells mature as osteoblasts or, in some
instances, as chondroblasts. The chondroblasts form car-
tilage and are found in varying amounts at a fracture site.
498
Osteoblasts lay down an intercellular matrix of collagen
and polysaccharide which then becomes impregnated
with calcium salts forming the immature bone called
callus or woven bone. This is visible on X-ray and gives
evidence that healing is taking place.
Consolidation
Osteoblastic activity results in the change of primary callus
to bone, which has a lamellar structure, and at the end of
this stage union is complete. New bone forms a thickened
mass at the fracture site and obliterates the medullary
cavity. The amount of this new bone varies for a number
of reasons. It tends to be more extensive if there has been
a large haematoma or it has been impossible to obtain
exact apposition of the bone fragments.
Remodelling
The lamellar structure is changed and the bone adapts by
strengthening along the lines of stress imposed upon it.
The surplus bone formed during healing is gradually
removed and eventually the bone structure appears very
similar to the original. In children, healing is usually very
graph. In adults there may be a permanent area of thicken-
ing, which might be felt or seen, in a superficial bone.
Healing of cancellous bone
This follows a different pattern from that described above.
As with compact bone, a haematoma will form, but as
there is no medullary cavity, the second stage differs. Can-
fragments of bone and penetration of the bone-forming
tissue is facilitated by the open arrangement of trabeculae
as it grows out from both fragments. Osteogenic cells lay
down intercellular matrix, which calcifies to form woven
bone. The process of remodelling then continues to form
the cancellous bone.
When is a fracture healed?
One of the most common questions asked by patients is
‘When will my fracture be healed?’ Unfortunately, the
answer to this question is not always straightforward and
depends upon many factors, including the type of bone
fractured, the type of fracture sustained, the age of the
person, the treatment undergone and the nutritional
status of the person.
The current mainstay for evaluating when a fracture is
healed is still based upon a combination of clinical judge-
ment, X-ray evaluation and historical knowledge on spe-
cific fracture behaviours. A fracture is considered to be
clinically healed based upon the combination of physical
findings and symptoms over time.

The following suggest complete healing:
• absence of pain on weight-bearing, lifting or
movement;
• no tenderness on palpation at the fracture site;
• blurring or disappearance of the fracture line on
X-ray;
• full or near full functional ability (Hoppenfeld and
Urthy 1999).
Time for a fracture to unite
The time it takes for a fracture to unite depends on a
number of factors.
• Type of bone. Cancellous bone heals more quickly
than compact bone. Healing of long bones depends
on their size so that bones of the upper limb unite
earlier (3–12 weeks) than do those of the lower limb
(12–18 weeks).
• Revascularisation of devitalised bone and soft tissues
adjacent to the fracture site.
• The mechanical environment of the fracture
(Marsh and Li 1999).
• Classification of the fracture. It is easier to obtain
good apposition of bone ends with some
fractures than with others. This may depend
on the initial position of the fragments before
reduction and the effect of muscle pull on the
fragments.
• Blood supply. Adequate blood supply is essential for
normal healing to take place. Certain fractures can
be notoriously slow to heal (e.g. fractures of the
lower third of tibia). This part of the bone has a
poor blood supply owing to the fact that under
normal circumstances it does not require one as
there is little muscle bulk here, therefore little
demand for nutrients and oxygen.
• Fixation. Adequate fixation prevents impairment of
the blood supply which may be caused by
movement of the fragments. It also maintains the
reduction thus preventing deformity and consequent
loss of function. Interestingly, if a fracture is rigidly
immobilised, the stimulus for callus to form is lost,
so a small amount of movement at a fracture site
actually encourages fracture healing.
• Age. Union of a fracture is quicker in children and
consolidation may occur at between 4 and 6 weeks.
Age makes little difference to union in adults unless
there is accompanying pathology.
• It has been suggested that certain drugs such as
non-steroidal anti-inflammatory drugs may interfere
with fracture healing; however, evidence remains
inconclusive (Bandolier 2004).
• Smoking. There are increased rates of delayed union
and non-union in people who smoke who have
sustained open tibial fractures (Adams et al. 2001).
An introduction to fractures Chapter 22
• Ultrasound. Recent work has suggested that low-
intensity ultrasound may accelerate fracture healing
(Azuma et al. 2001).
COMPLICATIONS OF FRACTURES
Critical blood disorders
Pulmonary embolism and deep vein thrombosis are two pos-
sible complications of a fracture. Shock may be caused by
hypovolaemia or loss of blood. Femoral shaft fractures
may bleed as much as three pints (1.7 litres) and pelvic
fractures may lose six pints (22.4 litres). Clinical signs of
this are tachycardia (rapid heart rate), pallor from reduced
peripheral perfusion, hypoxia (decreased oxygen satura-
tion), confusion, and a state of semi-consciousness.
Infection and tetanus are threats, especially following
open or compound fractures. Most people are now immu-
nised against tetanus or given booster tetanus injections if
they have a large open wound. Bone infection (osteomy-
elitis) can be stubborn to respond to treatment.
Fat embolism (acute respiratory
distress syndrome)
If a person sustains multiple fractures of large bones or
crushing injuries, or if large amounts of marrow become
exposed, there may be leakage of microscopic fat globules
into the circulatory system. These may become trapped in
the lungs. Symptoms include respiratory distress, short-
ness of breath, drowsiness, a decrease in saturation of
oxygen levels and petechiae (tiny haemorrhages which
appear on the chest). Acute respiratory distress syndrome
(ARDS) is potentially fatal.
Skin plaster sores
Reassure the patient that large amounts of dry flaky skin
following removal of plaster is normal. Reddened areas or
sores caused by plaster or splints must be reported to the
relevant team member.
Muscle damage and atrophy
Muscle fibres may be torn, crushed or ruptured as a result
of the injury and this will cause additional bleeding and
swelling. Tendons may be severed, particularly in the case
of open fractures, or sometimes there may be a rupture
following a fracture. Surgical intervention is usually neces-
sary to repair a rupture.
Compartment syndrome
If muscles become damaged or inflamed at the time of
injury, and intramuscular pressure builds up with no
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 Tidy’s physiotherapy
means of release, death (necrosis) of the tissues from
ischaemia (lack of blood supply) may result. It is defined
as the condition in which high pressure within a closed
fascial sheath reduces capillary blood perfusion below the
level necessary for tissue viability. Compartment syn-
drome is seen most commonly in the anterior tibial
muscles or forearm muscles.
Clinical signs of a limb with compartment syndrome
are the five P’s:
• pale;
• painful;
• pulseless;
• paraesthesia;
• paralysed.
Treatment revolves primarily around accurate diagnosis.
Check colour, sensation and movement after any injury
or surgery, elevate and cool the limb. Surgical decom­
pression (fasciotomy) may be necessary as an emergency
procedure.
Avascular necrosis
Bone receives its blood supply by the soft tissue structures
attached to it or by intra-osseous vessels. In certain
instances one part of the bone is very dependent on the
intra-osseous (within the bone) vessels for its blood
supply and if this is interrupted because of a fracture,
avascular necrosis may occur (part of the fractured bone
may die). It can occur in fractures of the neck of femur
leading to avascular necrosis of the head, and in fractures
of the scaphoid bone where the proximal pole may be
affected. This may be a cause of non-union of the fracture
and as the fragment usually includes an articular surface
it can lead to osteoarthritis.
Problems with union
Delayed union may occur if the gap between the bone
ends is too big, the blood supply is poor (lower third
of the tibia), the area is infected or if internal fixation
is used (this sometimes removes the stimulus for callus
formation).
There may be distinct pathological changes and radio-
logical evidence of non-union. There appears to be no
callus formation and the fractured ends of bone become
dense and the outline clear-cut. The gap between the bone
fragments may be filled with fibrous tissue and form a
pseudo-arthrosis. The lower third of the tibia has notori-
ously poor healing capabilities, even occasionally in the
young and healthy.
A fracture may heal in a less than perfect position –
malunion. Overlapping of the fragments could lead to
shortening and this would affect function. Angulation or
rotation of the fragments may impair function because of
the resulting altered biomechanics.
500
Growth disturbance
In younger people there may be growth disturbance if the
fracture includes the epiphysis (growth plate).
Complex regional pain syndrome I (CRPS I)
The term complex regional pain syndrome (also sometimes
known as Sudeck’s atrophy, reflex sympathetic dystrophy
(RSD), algodystrophy or causalgia) is now being used to
describe these pathological states. Fortunately it is a rare
complication. Patients complain of severe pain at rest, as
well as on movement, out of proportion to the initial
injury. The limb is swollen and the skin appears shiny
and discoloured, and feels cold. In extreme cases this
may lead to the limb becoming exquisitely tender and
discoloured. Osteoporosis and permanent contractures
may follow.
Management is difficult. When the lower limb is
involved, weight-bearing is encouraged with the help of
physiotherapy and pain control aids, such as transcutane-
ous electrical nerve stimulation (TENS). However, this is
minor therapy compared with the use of other treatments
such as sympathetic nerve blocks (Viel et al. 1999), vasodi-
lator drugs (e.g. guanethedine) and local analgesia. All of
them have variable results. Recovery is slow and may take
several months.
Intra-articular fractures
Fractures involving the articular cartilage predispose the
joint to osteoarthrosis in the future (e.g. fractures of
the tibial plateau). This is owing to the area of roughness
that inevitably results after a fracture and also because
the immobilisation of the fracture results in cartilage
death (see below). For the latter reason, some fractures are
now treated aggressively by physiotherapists from an
early stage.
Another problem with intra-articular fractures is that if
callus is attempting to form within a joint cavity, it is
constantly being washed away by synovial fluid.
Visceral injuries
A fractured pelvis may damage the bladder or urethra. A
fractured rib may cause a pneumothorax. A skull fracture
may cause brain injury. These are just three examples.
Adhesions
These may be within the joint (intra-articular) or around
the joint (peri-articular). Adhesions are the price paid for
immobilising a fracture. Intra-articular adhesions may
occur when the fracture extends into the joint surface and
there is a haemarthrosis, or bleeding within a joint cavity.
If this is not absorbed, fibrous adhesions may form within

the synovial membrane. Peri-articular adhesions may
occur if oedema is not reduced and is allowed to organise
in the surrounding tissues. This leads to adhesion forma-
tion between tissues such as the capsule and ligaments,
and results in joint stiffness, which is less of a problem
now that new techniques of fixation allowing early mobi-
lisation have been developed.
Capsular adhesions are common, for example in the
capsule of the shoulder joint which possesses dependent
folds on its inferior aspect to permit the huge range of
motion at this joint. These may stick together after fracture
or injury causing limitation of movement.
Injury to large vessels
If a large artery is occluded in such a position as to cut off
the blood supply to the limb, this may lead to gangrene
or, if there is partial occlusion, an ischaemic contracture
may develop. These injuries must be dealt with as an
emergency by the surgical team.
Thrombosis of veins may occur in the area of the frac-
ture. This presents as a sudden development of a cramp-
like pain in the part, by an increase of swelling and by
marked tenderness along the line of the vein. Anything
that appears to be abnormal in the circulatory system must
be reported to the surgeon immediately. Blood vessels may
sustain damage, for example following supracondylar
humeral fractures the brachial artery may be damaged.
Nerve injury
Certain fractures can lead to nerve palsy (e.g. radial nerve
injury in mid-shaft fractures or the common peroneal
nerve when a plaster is applied too tightly to the lower
limb). Functional bracing (e.g. ankle foot orthosis or AFO)
can be helpful while the nerve recovers. Sometimes bracing
has to be used long-term if the nerve does not recover.
Oedema
Oedema may be apparent below the level of the plaster
and it is often necessary to elevate the limb, exercise
the fingers or toes not encased in plaster, and perform
isometric contractions of the muscles within the cast
in an attempt to encourage muscle pump activity
(Tschakovsky et al. 1996; Sheriff and Van Bibber 1998).
Hold the fracture
(play it safe but run a higher
risk of other problems)
Figure 22.4  The mobilisation see-saw.
An introduction to fractures Chapter 22
Once the plaster has been removed, atrophied muscles
may not provide an adequate muscle pump on the
veins, in which case swelling may reappear especially
after activity or non-elevation.
PRINCIPLES OF FRACTURE
MANAGEMENT
Once a fracture has been diagnosed, the most suitable
treatment must be decided upon. This should be the
minimum possible intervention that will safely and effec-
tively provide the right environment for healing of the
fracture. Interestingly, nature has devised a system by
which a slight amount of movement at a fracture site
is useful in stimulating callus formation so there is a
balance to be made between immobilising a fracture
but allowing enough movement to stimulate callus for­
mation and healing (Figure 22.4; Cornell and Lane 1992).
This is a common dilemma in orthopaedics. In the same
way that there is no recipe for the physiotherapy treatment
of a fracture, there is no single recipe for the surgical man-
agement of fractures. This ‘see-saw’ will be referred to in
the case study presented later in this chapter.
Reduction
Reduction means to realign into the normal position
or as near to the normal anatomical position as possible
(Figure 22.5). Reduction of a fracture may be either
open or closed. Closed reduction means that no surgical
intervention is used with the fracture being manipulated
by hand under local or general anaesthesia. Open reduc-
tion means that the area has been surgically opened and
reduced.
Reduction may not always be necessary, even when
there is some displacement. For example, fractures of the
clavicle may heal with a bump which may be a problem
only in the cosmetic sense; function is the most impor-
tant end-point.
However, when there is poor alignment of the fragments
or the relative positions of the joints above and below the
fracture are lost as a result of angulation or rotation of the
bone ends, or if there is loss of leg length, then accurate
Move the fracture
(minimise complications/
early rehabilitation)
501
 Tidy’s physiotherapy

Figure 22.5  Reduction and healing of a fractured shaft of tibia showing the developing callus formation. (With thanks to Martin
George, Superintendent Radiographer; Sue Evans, Senior Radiographer; Lynn Porter, Sonographer; Southport and Ormskirk Hospitals, UK.)

anatomical reduction is necessary. X-rays are used to ascer-

tain the exact position of the fragments before and after
reduction. Real-time X-rays can now be taken using image
intensifiers so that the surgeon can more accurately reduce.
Improvements in computed tomography (CT) and mag-
netic resonance imaging (MRI) scanning mean that
complex fractures can be studied in great detail pre-
operatively, which assists the planning of surgery.

Immobilisation
The objectives of immobilising a fracture are:
• to maintain the reduction;
• to provide the optimal healing environment for the
fracture;
• to relieve pain.
In some fractures where there is no likelihood of dis-
placement, fixation may not be necessary or minimal fixa-
tion will suffice, for example buddy strapping for some Figure 22.6  Double buddy strapping applied to both sound
finger fractures (Figure 22.6). and damaged fingers to assist movement of the latter.

Common methods of fracture

immobilisation
Plaster of Paris
This is a plaster-impregnated bandage that can be moulded
to the part when wet, which sets in time. The standard
method of external splinting is still plaster of Paris
(Figure 22.7).
Synthetic materials are now used for splinting some
fractures because of their light weight and waterproof
qualities. Custom-made lightweight thermoplastics can be

502
 An introduction to fractures Chapter 22

Table 22.1  The advantages and disadvantages of

plaster of Paris

Advantages Disadvantages

• No surgery or its • It may not be possible

complications to reduce the fracture
• No infection risk correctly or maintain
• Quick to apply reduction
• Rapid patient discharge • May require surgery at
• Cheap, relatively easy a later date
to apply with training • Plaster needs removal/
• New lightweight casts or windowing (removal
are an alternative of a piece of the cast)
• Radio translucent (bones to inspect the skin
can be X-rayed through • May need removal in
the cast) case of increased
• May absorb fluids or swelling or reapplication
bleeding. The extent of once swelling has
Figure 22.7  Plaster of Paris immobilisation.
bleeding can be traced subsided
on the cast itself and • Bad odour if it gets wet
monitored daily • Heavy
moulded to the limb and remoulded if swelling or atrophy • Can be moulded for • May crack
cause changes in the limb contour. Some synthetic casting several minutes before • May rub the skin and
materials, however, are less malleable and cannot be hardening cause sores
moulded as effectively as plaster of Paris and they can
occasionally cause allergies.
A plaster saw is needed to remove a cast. This special The soft tissues of the limb squeeze against the inside
tool has an oscillating blade that will cut through the hard of the brace and, in conjunction with the use of a heel
cast without damaging the skin. cup, permit weight to be taken through the substance of
The advantages and disadvantages of using plaster of the brace. This has reduced many of the problems that
Paris are listed in Table 22.1. were seen as a direct result of prolonged immobilisation.
Another benefit of allowing movement of joints, provided
that it does not unduly stress the fracture site, is that it may
Clinical note promote union by improving the area’s blood supply.

Medical advice should be sought if any of the following Internal fixation

occur to a limb that is in a plaster of Paris or similar
splint:
• pale or blue coloration of the skin on the injured part;
• numbness, tingling or throbbing of the injured part;
• inability to move the fingers or toes;
• excessive pain in the injured part;
• swelling, bulging or puffiness around the edges of
the cast;
• a foul smell from under the cast;
• if it becomes loose and slides around.
Functional bracing (cast bracing)
It has been found unnecessary to fix some fractures as
rigidly as was thought necessary in the past. An example
of this is cast (or functional) bracing. Functional braces
have hinges to allow movement (see the case study towards
the end of the chapter and Figure 22.24).
Surgical intervention by applying a plate and screws to the
fracture is known as open reduction and internal fixation,
often abbreviated to ORIF (Figure 22.8).
Advantages of ORIF
It permits a detailed inspection and accurate surgical
assessment of the site of injury and procedure to be
undertaken.
Disadvantages of ORIF
• Surgery inevitably causes additional trauma and
potential exposure to microorganisms.
• It can convert a closed fracture into an open fracture.
• It requires surgery with all its sequelae and potential
complications. Ironically, rigid fixation may remove
the stimulus for callus formation. The implants are
usually left in unless they cause problems e.g.
irritation, infection or protrusion. In the young, they
will be removed if they will affect growth of the bone.

503
 Tidy’s physiotherapy
Figure 22.8  Fracture of the tibia/fibula fixed by plate and
screws.
Intramedullary nailing
Here, a hollow metal rod is introduced at one end of a
long bone, travels down the medullary canal and may be
locked with screws distally and proximally (Figure 22.9).
The proximal aspect of the nail is threaded and this
permits a tool to be threaded onto the nail at a later date
for its removal.
Intramedullary nailing for fractures of long bones has
revolutionised the management of many fractures, which,
historically, would have been managed by prolonged bed
rest. The trauma is less than with open techniques and
results in a shorter hospital stay, more rapid patient mobi-
lisation and rehabilitation with minimal risk of complica-
tions associated with immobility. The implant, rather than
the bone, may take stresses and strains, and, for this
reason, the surgeon may choose to remove the locking
screws at a later stage. This permits the nail to move
slightly and cause compaction of bone ends (dynamisa-
tion). It allows the bone to once again take its normal
stresses and strains and adapt in accordance with Wolff’s
law. The endosteal proliferation that occurs as part of the
normal fracture healing process may be lost with certain
types of internal fixation. Fractures of the shaft of tibia and
humerus may also be nailed in this way.
External fixation
Figure 22.10 shows fixation of a fractured tibia using an
external fixator. Pins or wires are driven into the fragments
504
Safety
margin
Must leave a 3 cm
safety margin from
the locking screw,
and a 3 cm safety
margin from the
distal end of the
thick ISKD rod.
Safety
margin
A B
Figure 22.9  Intramedullary nailing. (a) ISKD nail.
(b) Intramedullary skeletal kinetic distractor (ISKD) (With
thanks to Dania Sorio, Customer Service International, Orthofix
Srl and Grit Soboll, Communications Manager, Orthofix Srl,
www.orthofix.it.)
The intramedullary skeletal kinetic distractor
The intramedullary skeletal kinetic distractor (ISKD) is a
two-part metal rod that can be used for tibial or femoral
lengthening. An osteotomy is performed to allow
distraction to take place. The device can only rotate in one
direction and requires the patient to perform a rotational
movement to cause lengthening. A hand-held monitor
that contains a magnetic sensor is able to detect a small
magnet sealed inside the ISKD. As the ISKD lengthens, the
magnet rotates through 360 degrees. The monitor detects
these changes and is able to record measurements so that
lengthening can be very accurately controlled. Patients
take measurements regularly throughout the day. The
duration of lengthening depends on how much length
needs to be achieved. The average desired rate is usually
1 mm per day. Patients are generally non-weight-bearing
during the distraction phase.
and held by a piece of apparatus on the outside of the
body. Figure 22.11 shows an external fixator for a
comminuted intra-articular fracture of the distal radius.
Figure 22.12 shows an external fixator for an unstable
pelvic fracture.
The advantages and disadvantages of external fixation
are listed in Table 22.2.
 An introduction to fractures Chapter 22

Figure 22.11  Fixation of a comminuted intra-articular

fracture of the distal radius. (Photo reproduced by kind
permission of Ms Fiona Cobbold ©.)

Figure 22.10  Fixation of a fractured tibia using an external Figure 22.12  External fixator for an unstable pelvic fracture.
fixator. Pins or wires are driven into the fragments and held
by a piece of apparatus on the outside of the body, as
shown in the external view. (Reproduced by kind permission of
Mr R.F. Adam.)

The Ilizarov method

The Ilizarov method of fracture fixation originated in

Russia in the 1940s. It incorporates an axial system of
wires or pins fitted through the bone and connected to a
circular ring. It has proved successful in cases of non-union
(Schwartsman et al. 1990). This method also incorporates
the principle of ‘distraction osteogenesis’, and can be
used in the restoration of large skeletal defects, limb
lengthening and the correction of skeletal deformities
(Figure 22.13). Figure 22.13  Ilizarov fixation for fractured humerus and
scapula.

505
 Tidy’s physiotherapy
Table 22.2  Advantages and disadvantages of external fixation
Advantages
• Minimal disruption
to the fracture site
• Enables inspection of
the wound and fracture
• Can be adjusted with minimal trauma
• Can be used for limb lengthening procedures
• Can be used to pin multiple fragments
(e.g. comminuted fractures)
• Allows preservation of tissues in open or
compound fractures, de-gloving injuries or burns
Statement
No two orthopaedic patients are alike
No two assessments are alike
No two treatment courses are alike. Patients do not
always do what the textbook says!
No single assessment can predict the outcome
of the problem
Skeletal traction
In skeletal traction a Steinman pin is inserted through the
bone and a weight system attached to allow localised,
effective traction. Common sites for this are the tibial
plateau or the calcaneum. Pin sites must be kept clean
and free of infection. These pins are usually tolerated well
and are not as painful as they appear.
Traction
Figure 22.14 shows an example of skin traction. The trac-
tion force is applied through the skin instead of through
the bone.
Traction is the application of a pulling force to a part of
the body; it may be either a direct or an indirect pull. Trac-
tion is less common on the orthopaedic ward nowadays,
although it still has its place. Uses include:
• restoring bone or limb length if it has been reduced
by fracture or disease;
506
Disadvantages
• Infection risk at pin sites
• Needs meticulous wound care
• Cosmetically ugly
• Functional impairment (e.g. adjacent joints may be restricted
or soft tissues pierced by fixator)
• Anaesthetic risk and its associated complications
• Patient will need several days in hospital
• Stresses taken by implant, so decreased stimulus for
callus formation
• Heavy
Consequence for the physiotherapist
Do not ask for a ‘treatment recipe’. Your approach should
be flexible and dynamic and will change as a result of many
factors
Learn the basic assessment framework but tailor your
assessment slightly to each individual
Keep an open mind, recognise when a treatment is not working
and change or modify it
Experienced physiotherapists are able to ‘assess as they treat’.
This means that the patient is continually receiving the most
appropriate attention and the situation is dynamic. Treatment
goals may need modification and should not be totally
inflexible
• maintaining correct limb length and overcoming
muscle spasm, which may be the cause of limb
shortening after a fracture;
• to correct deformity in a joint;
• to reduce a dislocated joint;
• to immobilise a joint;
• to relieve pain pre-operatively;
• to promote rest and healing postoperatively.
PHYSIOTHERAPY AND FRACTURES
General issues
The physiotherapist’s role is to identify the cause of the
problem and to select the appropriate procedure to allevi-
ate or eliminate the cause of the loss of movement – ‘the
right tool for the right job’. For example, there is little point
in using accessory joint mobilisations if muscle spasm is
the limiting factor and a hot pack would not be appropri-
ate if there were a bony block to movement.
Assessment of each individual will dictate the rehabilita-
tion programme – there is no standard ‘recipe’ for the

Figure 22.14  Skin traction – this woman sustained a
fractured shaft of femur and, owing to her general health,
surgery was not indicated. She was managed conservatively.
(With thanks to K. McGregor.)
treatment of fractures. Any exercises given to a person
must be realistic, attainable, adaptable, functional and
memorable, as patients often become confused about
their exercises.
Most orthopaedic units have in place standardised
protocols/guidelines and postoperative care plans for
particular surgical or orthopaedic interventions, and the
physiotherapist should adhere to these. Providing the
best possible treatment to orthopaedic patients will take
many years of practice, reflection and fine-tuning of clini-
cal reasoning skills.
Clinical reasoning is not an abstract concept, it is
applying common sense to your knowledge base. Your
knowledge will improve every time you assess a patient
and evolves with experience. The following section gives
pointers about assessing patients who have sustained
fractures.
How physiotherapists assess and treat fractures depends
very much on the time elapsed since the fracture, and the
stage of rehabilitation at which they are performing the
assessment.
An introduction to fractures Chapter 22
For example, students are often dismayed on their clini-
cal placement to find that they are unable to perform a
complete assessment of a patient who has just been
put into plaster of Paris. Their treatment plan may now
consist of:
• attaining safe non-weight-bearing on elbow crutches;
• negotiating stairs safely;
• planning for safe discharge home;
• advising on isometric exercises.
Initial patient assessment
An assessment is essential if you are to plan out a safe
and appropriate treatment. Assess a fracture like any other
condition, but be aware of any specific instructions or
limitations. For example, is the patient allowed to fully or
partially bear weight? Take time and think about what
you are doing. If you omit something, make a note
and remember to follow it up next time. Your assessment
will vary considerably depending on the clinical setting
you are in.
The problem-oriented medical
record
The problem-oriented medical record (POMR) system is
based on a data collection system that incorporates the
acronym SOAP:
• Subjective – any information given to you by the
patient: allergies, past medical history, past surgical
history, family history, social history (living
arrangements, social conditions, employment,
medication), review of systems;
• Objective – all information obtained through
observation or testing, e.g. range of joint movement,
muscle strength;
• Analysis – a listing of problems based on what you
know from a review of subjective and objective data.
For patients with multiple problems, number and
list each problem consecutively, with the most
important listed first;
• Plan – as the name implies this refers to the plan of
forthcoming treatment.
Key point
Documentation is developing and many hospitals now
use multi-disciplinary integrated care pathways (ICPs) or
electronic health records (EHRs). The documentation of
your clinical reasoning and adherence to both your local
and Chartered Society of Physiotherapy Core Standards
of Practice is paramount.
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 Tidy’s physiotherapy

The subjective assessment and radiation of the pain. Is it related to time of day or
certain activities, and does it have alleviating or aggravat-
Basic background information to record ing factors? Visual analogue scales may be used as an
• Occupation. attempt to quantify pain (see Chapter 11). Remember that
• Drug history. dull aching of the fracture site may be considered normal,
• X-rays/scans/other tests. especially after activity. This may signify bone remodel-
• Family history. ling. Sharp pain of a prolonged nature is more cause for
• Date of next clinic appointment. concern – hence the need to understand the physiology
• Specific surgical instructions. underlying healing.

History of present condition The objective assessment

Include the date of onset, mode of onset, course and treat-
From the subjective assessment you should be able to
ment to date. Note specific instructions, for example
devise a plan for your objective testing. The symptoms will
partial weight-bearing for the next three weeks. If the
act as a guide to the structures that will be examined:
patient does not know his or her own postoperative
articular, muscular, vascular or neural. The painful areas
instructions, do not guess. Speak to the other team
should all be assessed, including areas other than the frac-
members to establish treatment parameters.
ture site with associated soft tissue injuries. The tests used
will be adapted to the stage in the healing process and the
Previous medical history
individual. By remembering the fundamental principles of
Are there any warning signs or findings that might affect fracture treatment (reduction, immobilisation and pre­
your treatment options? servation of function), the assessment can be completed
For example: effectively and without damage. With an unstable fracture,
• a person with internal fixation in place would not be for example, muscle contraction across the site could cause
considered for certain electrotherapy treatments; further damage. Fixators immobilise a fracture but are not
• a patient with advanced osteoporosis would not be as stable as union and should be treated with care.
considered for high-impact gym work; Convenient sub headings for your assessment are: look,
• diabetic patients may have neurovascular feel and move (Table 22.3).
complications that impact on the skin and healing;
• patients with a history of chronic obstructive Look
pulmonary disease (COPD) may have limited
mobility and exercise tolerance. The observational skills you develop over time will be
very important. A physiotherapist is often the first to pull
back the bed covers to find the overnight changes. The
Social history
changes in swelling, bruising, deformity, spasm, oedema
Do not underestimate the importance of asking the fol- and atrophy will indicate the progression of the pathology.
lowing questions: Leg length discrepancies, posture alignment and gait pat-
• Is the patient living alone? terns can be seen and then converted into objective
• Does the person need to go up stairs? measurements.
• Is the person losing money through not working?
• What are the person’s hobbies?
• Does the person care for sick relatives? Table 22.3  Objective examination
• What does that person need to be able to do to be
‘normal’? Look Feel Move
The most effective physiotherapists are able to listen to Swelling Swelling Active first
what the patient tells them and incorporate this into the Spasm Heat Then passive
treatment plan. Do not ask leading or multiple questions, Deformity Sensation Then overpressure (care –
but keep your questioning on track and relevant and do Bruising Tenderness on this may be inadvisable
not lose sight of why you are there. Set long- and short- Oedema palpation depending upon the
term goals as you would with any other patient, but be Atrophy Spasm stage of fracture
prepared to adapt them if necessary. healing)
What is the quality and
Pain amount of movement
and what is the
It is not sufficient to ask merely whether or not the patient
end-feel?
has pain. Ask the person about the location, type, duration

508

Feel
The palpation of swelling, pulses, heat, spasm and tender-
ness may be the main substance of your objective assess-
ment in the acute unstable fracture. They are also essential
for the detection of complications. Sensation changes will
indicate the extent of your neural testing.
Move
This section is used to design your exercise programme for
the preservation of function. A patient will be fearful of
movement and will rely on you to indicate what, and
how, to get moving. Therefore, it is essential to test joints
above and below the site to establish for the patient
the limitations of their condition. Local to the acute
unstable fracture passive or assisted active movements
would be less pain and harmful. However, in later stages
of the pathology, active, passive and then overpressure
testing is required. What is the quality and amount of
movement and what is the end-feel? In answering these
questions you will be able to diagnose the nature of the
damage.
The stage of the fracture healing will dictate the extent
of strength testing. Muscles that do not cross the frac-
ture site but move the limb should be assessed. Their
role as an agonist, antagonist, synergist or fixator will
influence the choice of test and the maintenance exer-
cises prescribed.
Functional movement tests are essential to tailor
your treatment to the individual; their abilities may be
influenced by their injury, age or comorbidities. By meas-
uring their ability to move about the bed, to get in and
out of bed, to maintain weight-bearing status and do stairs
will indicate discharge suitability. In the later stages the
tests may relate more to occupational or leisure needs.
The assessment allows you to pull together the subjec-
tive and objective findings to form a clinical diagnosis. You
may need to discuss this with your supervisor initially to
help clarify your reasoning, aid in goal-setting and the
treatment planning. To complete the planning stage it is
necessary to inform the patient of your findings and agree
the treatment plan.
Setting goals for orthopaedic
patients
Without goals we have nothing to measure our perform-
ance against. This simple summary should help you plan
goals for patients. When you set goals for any patient
(orthopaedic or otherwise) the goals need to be SMART:
• Specific
• Measurable
• Achievable
• Realistic
• Timely.
An introduction to fractures Chapter 22
Typical examples of orthopaedic goals possessing all the
SMART characteristics are:
1. Goal – Mr X will be able to safely negotiate stairs,
partial weight-bearing with two elbow crutches in
four days’ time.
2. Goal – Mrs Y will have attained 50 degrees of active
knee flexion by one week from today.
3. Goal – Mrs Z will be able to transfer safely from bed
to chair within two days.
Test yourself
Each of these goals fails to achieve one or more of the
SMART criteria. Why?
1. Mr X will be totally pain free within one day of
sustaining his fractured femur, tibia and humerus.
2. Mr X will be able to walk in eight months’ time.
3. Mr X will be much better in one week.
4. Mr X will mobilise full weight-bearing on the unstable
fracture within one week.
5. Mr X will have more knee flexion within one week.
Answers
(1) Not realistic. It is extremely unlikely that Mr X will be
totally pain-free one day after three such major fractures.
(2) Not timely. The end-point of this goal is too far in the
future. (3) Not specific – what does ‘much better’ mean?
(4) Not achievable. The orthopaedic protocol does not
permit this. (5) Not measurable and not specific – what
does ‘more’ mean?
General points
Think about how you will realistically progress your treat-
ment and how you will measure any progression (e.g. grip
strength, isokinetic machine, goniometry). Work as part of
the multi-disciplinary team (MDT) and think about who
else needs to have input into the case, but, at the same
time, do not forget your own role. Be aware of potential
complications, reassure and encourage your patient – who
is the most important member of the MDT. Make the
patient responsible for his or her own recovery – a partner
in fact. Home exercises should be clear, practical and mon-
itored. Reassess progress as necessary. Are you attaining
your goals? If not, change or modify your goals or your
treatment. Before you discharge the patient remember that
a normal limb needs:
• full active movement;
• accessory movement;
509
 Tidy’s physiotherapy
• full strength;
• full function;
• anything else specific to that patient.
Does the patient need follow-up appointments or dom-
iciliary physiotherapy? The physiotherapist is a member of
the MDT. The membership and relative roles of this team
change according to the nature of the injury and the stage
of treatment but the physiotherapist must liaise and work
with the other members throughout the rehabilitation
period. Initially, if the patient is in hospital the members
of the team will include: the patient, medical staff, nurses,
occupational therapist, pharmacists, radiographers, dis-
trict nurse and corresponding domiciliary staff.
COMMONLY ENCOUNTERED
FRACTURES AND SOME PRINCIPLES
OF MANAGEMENT
Fractures of the upper limb
Fractures of the clavicle and scapula
Scapular fractures are not particularly common and
usually occur as a result of direct trauma. The clavicle often
fractures following a fall on to the side or as a result of a
fall on an outstretched hand. The fracture is usually in the
middle or the junction of the outer and middle thirds of
the bone. The pull of sternocleidomastoid muscle can
cause displacement.
These fractures are usually immobilised by a brace, a
sling, or a collar and cuff. Complications include a re­­
stricted range of movement in the shoulder girdle or
shoulder joint, as the two work together, and associated
muscle weakness.
Fractures of the proximal humerus
Fractures of the proximal humerus may be classified using
the Neer classification:
• Group 1 – minimal displacement;
• Group 2 – anatomical neck fracture with less than
1 cm displacement;
• Group 3 – displaced or angulated surgical neck;
• Group 4 – displaced fracture of greater tuberosity;
• Group 5 – fractures of the lesser tuberosity;
• Group 6 – fracture dislocations.
Fractures of the surgical neck of humerus
These usually occur in elderly people as the result of a fall
on the outstretched hand. There may or may not be dis-
placement of the fragments, but in a large number of cases
the fragments are impacted. This means that one bone
fragment has been driven into the other, often stabilising
510
the fracture at the time of injury. Displaced fractures, and
particularly those occurring in the elderly, are not usually
reduced for a number of reasons:
• lack of good alignment does not affect union;
• it is preferable to avoid surgery in the elderly unless
essential;
• early movement is important to avoid a stiff shoulder.
Fractures of the shaft of the humerus
These fractures usually occur in the middle third of the
bone and may be a result of direct or indirect trauma.
Direct trauma may give rise to transverse or oblique frac-
tures and sometimes present as comminuted fractures.
Displacement may result owing to muscle pull, and if the
fracture is below the insertion of deltoid the upper frag-
ment will be abducted. Indirect trauma tends to give a
rotational force resulting in a spiral fracture.
In stable fractures the fixation can be minimal and
consist of a sling alone or with a posterior slab from below
the shoulder to the wrist with the elbow at 90°. This
allows the weight of the arm to maintain reduction. If the
fracture needs sturdier fixation, intramedullary nailing is
possible or a complete plaster from the shoulder to the
wrist or hand may be applied.
Because the fracture usually occurs in the middle part
of the shaft, the radial nerve may be affected as it winds
through the radial groove. As the radial nerve supplies the
wrist and forearm extensor muscles, a wrist drop may
result. The injury may compress the radial nerve and
cause a neuropraxia, or if it is stretched it may result
in axonotmesis. Normally, these will recover spontane-
ously although an axonotmesis will take longer as degen-
eration of the nerve has occurred within the sheath.
Patients are usually given a wrist splint, to support the
wrist in extension, while the nerve is healing. In an open
fracture the radial nerve may be severed resulting in a
neurotmesis; this will require surgical suturing.
Delayed union or non-union can be complications but
they are not very common.
Fractures of the condyles of the humerus
These fractures are common in children following a
fall. A supracondylar fracture is the most common type
(Figure 22.15). After reduction the arm may be immo­
bilised in one of the following ways depending on the
type of fracture:
• plaster with the elbow at approximately 90 degrees
or a little more and extending from below the
shoulder down to the wrist or hand (the plaster
should be cut so that it is possible to feel the radial
pulse at the wrist);
• a posterior slab plus a collar and cuff;
• a collar and cuff.

Humerus
Brachial artery
Ulna
Figure 22.15  Supracondylar fracture of the humerus.
Some fractures of the condyles may extend onto the
articular surfaces and thereby cause additional problems.
One of the most serious complications that can occur is
damage to the brachial artery, which could be severed or
contused owing to its close proximity to the fracture site.
Therefore, circulation must be monitored. Impairment of
the circulation requires emergency treatment, as occlusion
can lead to irreversible ischaemic effects within a few
hours. If the circulation is not restored, Volkmann’s
ischaemic contracture may develop. This affects the flexor
muscles of the forearm. Muscle tissue is replaced by fibrous
tissue which contracts and produces flexion of the wrist
and fingers. The skin and nerves will also be affected by
the diminished blood supply.
Another problem following elbow fractures is post-
traumatic ossification – sometimes known as myositis
ossificans. If there is a severe injury, the periosteum may
be torn from the bone resulting in bleeding and the for­
mation of a haematoma. Osteoblasts invade this blood
clot and new (ectopic) bone forms. This can also occur as
the result of forced extension of the elbow. First indica-
tions that this is developing may be pain and loss of
movement. The elbow should be rested in a sling or collar
and cuff for about three weeks to allow the haematoma
to be absorbed. If this does not occur and bone is formed
it may be necessary to remove the bone tissue surgically.
If deformity develops at the elbow – such as a cubitus
valgus – this may cause a stretch on the ulnar nerve,
which may require surgical intervention with a trans­
position of the nerve from the posterior to the anterior
aspect of the elbow. Fractures that extend onto the ar­­
ticular surfaces and cause disruption of the joint may
An introduction to fractures Chapter 22
cause a permanently stiff elbow, lead to the development
of osteoarthritis or both.
Fractures of the radius
Radial head fractures
Management of radial head fractures ranges from no
immobilisation at all in undisplaced fractures, to screw
fixation, excision or replacement arthroplasty.
With fractures of the radius and/or ulna, both bones
may be fractured as a result of direct or indirect violence
such as a fall on the outstretched hand. The resulting
displacement may be difficult to correct and, in some
instances, may require open reduction. Accurate anato­
mical reduction is very important because loss of the
normal relationship between the two bones may result in
impairment of pronation and supination – a very impor-
tant component of hand function. In children, the damage
may not be so severe and they may sustain a greenstick
fracture with minor angulation which normally will heal
without any complications. Fracture of the ulna with
radial head subluxation is called a Monteggia fracture,
while fracture of the radius and subluxation of the lower
end of ulna is called a Galeazzi fracture.
Fractures of the distal radius
Fractures of the distal radius are described by their
angulation (dorsal or volar), whether they are intra- or
extra-articular and the degree of comminution. They are
common, particularly in the elderly, as a consequence of
osteoporosis (Figure 22.16a, b, c).
These fractures are reduced and immobilised with a
complete plaster cast, or backslab, from just below the
elbow to the hand, ending just above the proximal crease
on the palm. The position of the wrist and whether or not
there is a complete plaster will depend on the pattern of
the displacement. If there is gross swelling it may be neces-
sary to use a plaster back slab and then a complete plaster
when the swelling has reduced. Fixation is usually main-
tained for 4–6 weeks.
These fractures used to be known as Colles’ (dorsal
angulation) and Smith’s fractures (volar angulation).
Fractures of the proximal radius are less common and
tend to occur in younger people following either a direct
blow or a fall on the outstretched hand which causes a
fracture through the head of the radius. Fractures of the
ulna alone are not as common as those of the radius.
There are a number of complications that can occur
with fractures of the lower end of the radius, although
these are rare considering the numbers of fractures dealt
with in fracture clinics. Complications can include:
• loss of shoulder movement if it is injured when the
patient falls or as a consequence of wearing a sling
or collar and cuff;
511
 Tidy’s physiotherapy
C
• rupture of the extensor pollicis longus, occurring 4–8
weeks after the fracture;
• Sudeck’s atrophy;
• median nerve neuritis if displacement causes
stretching or compression of the nerve.
Fracture of the scaphoid
This fracture tends to occur in young adults as the result
of falls on the outstretched hand. It may be overlooked
either because the person considers it to be a strain, or the
fracture may not be visible on the initial X-ray. Healing is
often slow in this fracture and, in some instances, there
may be non-union. In the latter case the arm is usually
placed in a so-called ‘scaphoid plaster’ as a precaution and
512
Figure 22.16  (a–c) Colles’ (dinner-fork) fracture.
X-rayed again after a couple of weeks. If these fractures are
accurately diagnosed within one week followed by plaster
immobilisation, non-union can be prevented (Roolker
et al. 1999).
If the fracture occurs through the waist of the
bone the blood supply to the proximal part of the bone
will be impaired and avascular necrosis may develop.
Long-term complications include the development of
osteoarthrosis.
Fractures of the phalanges or metacarpals
Accurate anatomical reduction and fixation is essential,
but it is also important to keep the period of immobilisa-
tion as short as possible if a good functional result is to

be obtained. The position of the fixation will vary depend-
ing on which phalanx or phalanges are fractured and on
the subsequent stability of the reduced fracture. This can
be very important in relation to regaining function of the
hand, and the team has to decide on the priorities in each
case. The optimal splinting position for the hand ensures
that the metacarpophalangeal (MCP) joints are held in 90
degrees of flexion with the interphalangeal (IP) joints in
neutral. This ensures that the MCP collateral ligament
length is maintained preventing contractures and loss of
range of motion and function.
In stable fractures, a buddy strap splint may be used
which fixes the injured finger to the adjacent finger and
gives some support while encouraging some movement.
Bennett’s fracture
This is a fracture dislocation affecting the carpometacarpal
joint of the thumb.
Fractures of the lower limb
Definition
The patient’s weight-bearing status is dependent on
many factors, including the type of fracture, quality of
bone, age of the patient and the orthopaedic
management undertaken.
Fractures of the pelvis
The pelvis may be thought of as a ring; like a ring it will
often break in two places at once. An isolated fracture is
not, as a rule, serious unless it is complicated by damage
to the internal organs. The same is true of double, or even
multiple fractures, provided that there is no fracture or
dislocation in the iliac segment. However, if there are two
or more fractures or dislocations with at least one in each
segment, then the displacement may be considerable.
The majority of pelvic fractures are caused by direct
violence, falls or following crushing injuries. In major
pelvic trauma the blood loss sustained by the patient at
the time of the injury or from damage to the internal
organs may be a life-threatening complication. When the
pelvic ring is severely disrupted then rapid reduction and
fixation is necessary. If it is possible to reduce the displace-
ment manually then fixation may be by means of a plaster
spica, but otherwise another method of external fixation
may be used by placing pins through the iliac bones and
fixing to a transverse bar. Skeletal traction may be used for
certain pelvic fractures. Complications may include inju-
ries to the bladder or urethra and possibly to other tissues
within the pelvis.
An introduction to fractures Chapter 22
More common fractures include pubic ramus fractures
(secondary to osteoporosis) which are managed conserva-
tively with analgesia and gradual mobilisation. These frac-
tures can be very painful as the hip adductors have their
origin in this area, so walking is, understandably, painful.
The skill as a physiotherapist here is to gain the
confidence and respect of the patient and gradually
mobilise the person to recovery. It also highlights the
need for teamwork when co-ordinating analgesia with
mobilisation.
Avulsion fractures occasionally occur in the pelvis at the
anterior iliac spines, more specifically at the attachment of
rectus femoris and sartorius. They are caused by forcible
contraction of the muscle, pulling off the tip of the bone.
Fracture of the neck of the femur
This is probably the most common and most significant
fracture in terms of morbidity, mortality and socioeco-
nomic impact in developed countries (Reginster et al.
1999). Mortality after fracture is high: Schurch et al.
(1996) found that the one-year death rate was as high as
23.8% following a fractured neck of femur (Figure 22.17).
Femoral neck fractures should be described/classified by
its location, for example basicervical and whether it is
intracapsular or extracapsular, as this has a bearing on the
surgical fixation chosen (Figure 22.18). Classifications are:
• subcapital;
• transcervical;
• basicervical;
• intertrochanteric;
• subtrochanteric.
They are also referred to as Garden’s classification;
however, this terminology is not as current as it was but
may still be present in the literature.
1
2
3
4
5
Figure 22.17  The Garden classification of femoral neck
fractures: (1) subcapital; (2) transcervical; (3) basicervical;
(4) intertrochanteric; (5) subtrochanteric.
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 Tidy’s physiotherapy

A B C

Figure 22.18  Methods of fixation for femoral neck fractures: (a) k wire; (b) cannulated screw; (c) dynamic hip screw (DHS).
(Reproduced from Dandy and Edwards (1998), with permission.)

Femoral neck fractures are extremely common in the

elderly, often following falls, and most orthopaedic units
will have a number of these fractures at any one time. The
architecture of the bone may have been so weakened that
patients say that they ‘heard a crack’ before they hit the
ground. In other words the fracture caused the fall, not
the fall the fracture. Osteoporosis is often referred to as the
silent epidemic as it may not present any clinical signs
until fracture.
The resulting fracture is usually displaced with lateral
rotation of the femoral shaft so that the leg will be laterally
rotated and shortened in comparison with the other limb.
Occasionally, the fragments are impacted in slight abduc-
tion and the patient may be able to get up and walk
after the injury. Displaced fractures will need operative
fixation. For intracapsular fractures the usual method is to
excise the head and perform total hip replacement arthro-
plasty, although a hemiarthroplasty is still used in some
patients (Figure 22.19). This is the method of choice for
displaced fractures because of the dangers of avascular
necrosis and because of the benefits of early mobilisation,
which is so important in the frail. For more active older
people who have fewer comorbidities, orthopaedic sur-
geons are increasingly choosing to fix the fracture with a
total hip replacement.
For extracapsular fractures, where the blood supply is
not impaired, a compression screw plate called a ‘dynamic
hip screw’ is used. This allows dynamic movement at the Figure 22.19  Thompson’s hemiarthroplasty.
fracture site which stimulates healing – more so when
patients weight-bear through the affected limb. Subtron- Complications
chanteric fractures are routinely fixed with a proximal The blood supply to the femoral head is predominantly
femoral nail. Minimally displaced (e.g. Garden type 1) via a periarticular anastomosis (Palastanga et al. 1998).
fractures may be managed by cannulated screw fixation. Avascular necrosis (death of part of the bone owing to lack
Both the last two procedures are likely to involve a weight- of blood supply) can occur as the blood supply to the
bearing restriction for the patient on the affected side until head of the femur may be impaired following a fractured
the bone becomes stronger. neck of femur (Figure 22.20).

514

Synovial sheath
Ligamentum teres
Branch from
obturator artery
Femoral artery
Medial circumflex
femoral artery
Lateral circumflex
femoral artery
Profunda branch
Figure 22.20  Arterial supply to the hip. (Reproduced from
Palastanga et al. (2002), with permission.)
Fractures of the shaft of the femur
These fractures are usually the result of severe violence and
may occur at any part of the shaft, and may be of any type
– transverse, oblique, spiral – and may be comminuted.
Usually, there is marked displacement with overlap of the
fragments, which could lead to limb shortening if it is not
corrected. Angulation may occur depending on the injury
and on powerful muscle spasm pulling the fragment in
the direction of the attached muscles.
For children under the age of three years ‘gallows’ trac-
tion may be used. A modern, more acceptable alternative
to traction is the use of an intramedullary nailing (Figure
22.9) which can be performed by the closed technique.
The nail is passed through the greater trochanter and
down the medullary canal of a long bone and through the
fracture site. This is preferable to the previously favoured
method of prolonged traction or open reduction, as there
is less risk of infection and the complications of bed rest
and immobility.
If the fracture is an open fracture there is a risk of infec-
tion. Delayed union or non-union is occasionally a com-
plication of this injury, as is malunion. If the overlap of
the fragments is not reduced or there is redisplacement,
this can occur with consequent shortening of the femur.
When the fracture has been fixed internally with an
intramedullary nail, mobilisation can occur more rapidly.
More comminuted femoral fractures could be fixed with
external fixation (e.g. an Ilizarov frame) at the specialist
centres.
Fractures around the knee
These include fractures of the tibial condyles, the patella
and the femoral condyles.
An introduction to fractures Chapter 22
Injury to the tibial condyles may comprise either a com-
minuted compression or a depressed plateau fracture. In
the former, reduction is not usually attempted and early
mobilisation is encouraged. Depressed plateau fractures
require reduction to try to achieve an anatomically correct
articular surface. In complex tibial fractures, surgery is
often undertaken to prepare the area for a subsequent total
knee replacement where onset of traumatic osteoarthritis
is anticipated. Constant passive motion may be used
immediately after the fracture or after surgery to preserve
synovial sweep and maintain articular cartilage nutrition.
Fractures of the femoral condyles are not very common
but a supracondylar fracture occurs more frequently.
Complications
• A stiff knee could occur as the result of adhesions or
because of disruption of the articular surfaces in
fractures of the tibial condyles or patella.
• Secondary osteoarthritis may occur as a late
complication following disruption of the articular
surfaces.
• Genu valgum may develop following depression of
the lateral tibial condyle.
• Haemarthrosis may be a problem after fractures of
the tibial condyles. This may need to be aspirated
(drained) and bandaged, but the swelling that occurs
as a result of a synovitis will gradually absorb. If
other soft tissue structures are damaged there may be
further swelling, in which case the limb should be
elevated to assist drainage.
Fracture of the patella
This can be caused by a direct blow on the knee or a
sudden violent contraction of the quadriceps resulting in
an avulsion fracture. The former tends to cause a crack or
comminuted fracture whereas the latter may produce a
transverse fracture. Internal fixation may be required if
there is separation of the fragments.
Fractures of the tibia and fibula
These fractures are common and occur at all ages as a
result of direct or indirect violence. Often, they are open
fractures either because of the direct violence or because
the anterior tibia is very close to the surface and the frag-
ments may extrude through the skin.
Direct violence, commonly owing to road traffic acci-
dents or soccer, is likely to give an oblique or transverse
fracture. It may be comminuted and further complicated
by soft tissue damage. Fractures caused by a rotatory force,
such as may occur in skiing, are usually spiral and the
fractures of the two bones are at different levels.
Fixation will depend on the type of fracture and the
amount of soft-tissue damage. A functional brace with a
515
 Tidy’s physiotherapy

A B C D E
Direction
of force

F G H
Direction
of force
Figure 22.21  (a–e) Fractures resulting from an abduction/lateral rotation force: (a) fracture of lateral malleolus; (b) avulsion
fracture of medial malleolus; (c) fracture of lateral malleolus, rupture of medial ligament and lateral shift of talus; (d) fracture
of lateral and medial malleoli and lateral shift of talus; (e) tibio-fibular diastasis – rupture of tibio-fibular and medial ligaments,
fracture of shaft of fibula and lateral shift of talus. (f–h) show fractures resulting from an adduction force: (f) fracture of
medial malleolus; (g) avulsion fracture of lateral malleolus; (h) fractures of lateral and medial malleoli plus medial shift of talus.

hinge at the ankle may be used and this has the advantage
of allowing more movement and a better walking pattern.
If there is a lot of soft tissue damage and consequent swell-
ing, a split plaster may be applied and the leg elevated on
a Braun frame. This is replaced with a plaster once the
swelling has subsided.
Another method that is used to immobilise this fracture
is external fixation. Sometimes internal fixation is used
with either an intramedullary nail or plate and screws.
Common practice now is to commence active movement
in elevation immediately after surgery and delay the
application of a plaster until movements are sufficiently
regained.
Complications
Fractures of the tibia or fibula alone are not very common.
Infection is a possible complication as many of the frac-
tures are open. Antibiotics are used to help avoid this and
careful wound care is important. The tibia can be the site
of a stress fracture owing to repeated minor trauma, prob-
ably associated with sport.
Vascular impairment can occur owing to damage to a
blood vessel or a plaster cast that is too tight. Great care
must be taken by all concerned with the management of
these patients to monitor for any signs of circulatory defi-
ciency. Fractures can be very slow to heal (delayed union)
or there may be a non-union owing to poor blood supply
in the lower third of the tibia. Compartment syndrome is
another common complication.
Fractures around the ankle
Figure 22.21 shows fractures resulting from an abduction/
lateral rotation force or an adduction force. Complications
include limitation of movement in the ankle joint and
foot resulting from peri-articular and intra-articular adhe-
sions or from disruption of the articular surfaces. The latter
may also lead to the later development of secondary
osteoarthritis.
For fractures without displacement, a below-knee
walking plaster may be applied for 3–6 weeks. When there
is displacement it is important for the surgeon to try to
ensure that reduction establishes the normal anatomical
rela­tionship at the ankle joint. If reduction cannot be
attained by manipulation and plaster immobilisation it
may be necessary to have an ORIF and use a screw (or
screws) to maintain a good position of the fragments,
followed by immobilisation in a below-knee plaster.
The modern trend is towards immediate postoperative
active exercise (with adequate analgesia), then subsequent
application of a cast once good movement (particularly
dorsiflexion) is attained. A Tri-malleolar fracture involves
fractures of both the medial and lateral malleoli, as well
as fracture of the posterior tibial malleolis. Tri-malleolar
fractures are generally unstable.

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 An introduction to fractures Chapter 22

Fractures of the foot also cause soft-tissue damage and, consequently, swelling
is likely to be severe. These fractures do not, as a rule,
Fractures of the calcaneum usually occur as the result of a
require reduction or immobilisation. However, a below-
fall from a height on to the feet, fracturing the calcaneum
knee walking plaster is usually applied for fractures of the
in one or sometimes both feet. It may well be accompa-
metatarsals to relieve pain and enable the patient to walk.
nied by a fracture of one of the lower thoracic or upper
If swelling is severe the patient will need to rest in bed
lumbar vertebrae. (Take note if a patient with a fractured
with the leg elevated for a few days.
calcaneum complains of back pain.) Calcaneal fractures
Another type of fracture that occurs in the metatarsals
can be extremely painful and carry a poor functional
is a stress fracture – often known as a ‘March’ fracture. It
prognosis if inversion and eversion are not regained, as
is caused by repeated minor trauma that may arise from
their movements are essential for normal function of the
prolonged walking, particularly on hard surfaces, and
foot in such activities as adapting to uneven surfaces.
usually in someone who is unaccustomed to walking long
These may be managed either conservatively or by open
distances. It is usually a crack fracture affecting the shaft
reduction and internal fixation.
or neck of the second or third metatarsal. No fixation is
The emphasis of physiotherapy management is on the
required but a walking plaster may be applied if the pain
reduction of the oedema and mobilisation. Once the
is severe.
patient is allowed to bear weight it is important to
re-educate gait, as well as concentrating on strengthening
muscles and regaining range of movement in the ankle Complications
and foot. It may not be possible to regain any movement Complications include stiffness, particularly if there has
at the mid-tarsal joints and the patient will have to learn been disruption of the articular surfaces of the subtalar
to adapt to this loss of movement. The arches of the foot joint. Secondary osteoarthritis may develop later as a result
may have flattened and this could be the result of weak of the disruption of the joint surfaces.
muscles, deformity of the foot or both. In the former case
the muscles can be strengthened, but if the latter is the
case the arches will not reform: the patient may continue Spinal fractures
to have persistent pain and tenderness for a long time after
These are not dealt with in this text.
the fracture has healed and it is difficult to relieve.
Generally speaking, it is advisable to commence
early active mobilisation in elevation. Cryotherapy/TENS,
flowtron boot and patient-controlled analgesia (PCA)
have all been used with success. In later stages, accessory CRYOTHERAPY
mobilisations to the affected joints may be appropriate.
The phalanges and metatarsals are most likely to be This is regularly used in the orthopaedic setting and is
fractured by a heavy object falling on the foot. This will covered in Chapter 12.

Continuous passive motion (CPM)

Use of a CPM machine is variable in the orthopaedic setting (Figure 22.22a, b).
Like any other modality in medicine, it has its place and its limitations. Salter (1993) has made an interesting study of the
uses of CPM.

BENEFITS OF CPM
• There is maintenance of synovial sweep and thus hyaline articular cartilage nutrition. This is useful after certain
intra-articular fractures (e.g. tibial plateau).
• Regular rhythmical motion can act as an analgesic, can stimulate circulation and may assist in the reduction of swelling.
• CPM has been used following anterior cruciate reconstruction, particularly following patellar tendon graft. It is possible
that this encourages more rapid revascularisation and therefore strength of the donor graft.
• It is possible to increase the flexion/extension in a controlled manner that is immediately obvious to the patient and can
assist in giving the patient a goal to strive for.
• Some units have counters so that the healthcare team can tell exactly for how long the patient has been using the unit.
• CPM units are now available for shoulder, wrist and other joints.
• CPM units may now be used in the patient’s home.

517
 Tidy’s physiotherapy

Continued

DISADVANTAGES OF CPM
• It is passive and, therefore, by definition will not build muscle strength. Some patients mistakenly neglect active
exercises in the belief that they no longer need to undertake them. It is the responsibility of the physiotherapist to
ensure that this situation does not occur.
• Some patients are distressed by the appearance of the unit and feel threatened. Most units have a panic button so the
patient can stop the unit for rest, meals or toiletting.
• The units can be bulky and expensive.
• If incorrectly positioned they can cause pressure problems and be uncomfortable.
• They pose an infection risk if not properly cleaned and policies for their use followed.

Figure 22.22  A demonstration of a continuous passive motion (CPM) machine. (With thanks to Joanne Kenyon.)

518

CASE STUDY: FRACTURED SHAFT OF THE FEMUR
Note that the material in this section does not represent a
recipe for the management of all fractures of the femur.
BACKGROUND
Ms Jones is a 25-year-old law student who was involved
in a road traffic accident. She was driving and as a result
of a head-on collision the dashboard was pushed
backwards into her knees. She sustained a fractured shaft
of the left femur (Figure 22.23a) and was treated by
intramedullary fixation (Figure 22.23b). Ms Smith spent
ten days in hospital and has now come to the outpatient
physiotherapy department. She did not sustain any other
injuries.
ON EXAMINATION
Ms Jones is partial weight-bearing and is mobilising with
two elbow crutches and wearing a functional (cast) brace.
She is independently mobile, but needs help to remove
her training shoe and sock. The brace was custom-made
by the occupational therapists (Figure 22.24) and it is
unlocked to permit 0–90 degrees of knee flexion. The
physiotherapist may unlock the brace by a further 10
degrees each week. The patient must wear the brace
when walking but is permitted to remove it to perform
knee flexion exercises and to take a shower.
She is extremely anxious about what is going to
happen to her and confused about how much or how
little she should be doing. The only exercise she can
A B
An introduction to fractures Chapter 22
remember is the straight leg raise (SLR). She is articulate,
co-operative and keen to take advice. She cannot
currently attain heel strike and she states that this is
because it causes her calf to be painful (deep vein
thrombosis has been excluded). She has been told to keep
moving and, as a result, she is walking long distances
every day. Her leg aches badly at bedtime and she is
worried that the fracture has ‘moved’, although X-rays
show that it has not displaced since the time of surgery.
OBJECTIVE EXAMINATION
There are two incisions: one proximal to the greater
trochanter, one lateral to the knee joint. These have
healed. The patient has a reddened area over the lateral
malleolus, which is a result of the brace rubbing her skin.
Knee joint
The range of movement of the knee joint with the brace
removed is shown in Table 22.4.
Patello-femoral joint
All accessory movements are reduced by approximately
50% on the left side.
Ankles
There is full active range plantar flexion in both ankles.
Terminal dorsiflexion of the affected side causes calf
‘tightness’ when the left knee is in the fully extended
Figure 22.23  (a) The femoral fracture. Note
that spasm in the quadriceps has resulted in
overriding of the fracture fragments. (b) Note
the locking screws and skin staples visible on
X-ray.
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 Tidy’s physiotherapy

Continued

Table 22.4  Features of the patient’s knee joint

Left knee Right knee

Passive* Active† Over-pressure§ Passive Active Over-pressure

Flexion 0–60 0–40 – 130 130 –

Extension Full extension possible but causes posterior Full 0-degree extension painless
knee discomfort

Lateral rotation Full Full

Internal rotation Full Full

*Limited by apprehension. Limited by aching at the fracture site and quadriceps spasm. §Not tested in view of fracture status and
†

patient apprehension. The units are degrees.

Table 22.5  Features of the patient’s muscle

strength (Oxford grade)

L R

Quadriceps 4 5

Hamstrings 4 5

Tibialis anterior 4 5

Gastrocnemius 4 5

Figure 22.24  The functional brace. The heel cup is essential

for correct off-loading of weight from the fracture. (Courtesy
of Mike Somervell and Julie Butler.)

At rest After exercise

No pain Worst pain

imaginable
Figure 22.25  The patient’s pain scale.

position. The range of plantar and dorsiflexion is full, Limb girth

however. Small joints of the foot, intertarsal and tarso-
metatarsal, have some loss of accessory movement of the
subtalar and intertarsal joints of the affected side. There is
some oedema of the ankle. Capillary filling is poor.
Muscle strength
(Oxford grade – left:right) (See Table 22.5).
Pain
Figure 22.25 shows the pain recorded using a visual
analogue scale.
See Table 22.6.
SHORT-TERM PROBLEMS
Do not underestimate the impact of apprehension and
confusion. If a person is nervous, frightened or confused,
whatever you plan to tell, teach or ask of them, will be
adversely influenced. Do not think only of the fracture
– take a holistic approach. Physiotherapists are not
technicians, they are also educators. It is perfectly valid to
undertake with her a teaching session on fracture healing

520

Continued
Table 22.6  The patient’s limb girth
Limb girth 10 cm above 20 cm above
patella apex patella apex
Left leg 48 cm 44 cm
Right leg 56 cm 52 cm
and to discuss your aims of treatment. This might seem
time-consuming but consider your aims of treatment and
your role as her physiotherapist. The quality of your
communication and subsequent discussion of your
management plan will influence her eventual health
outcome. There is now strong research evidence
suggesting a positive correlation between effective
professional–patient communication and improved patient
health outcomes.
The sore caused by the brace is a high priority.
The physiotherapist needs to refer the patient to the
occupational therapist for adjustment of the brace. If
the sore develops to the point where she cannot tolerate
the brace, your ability to progress her treatment will be
adversely affected.
Pain and aching at the end of the day is normal
– your goal here is to explain why the pain is happening
and that it signifies bone healing. Do not assume that
your patient will automatically know this. Some patients
equate pain with ‘no pain no gain’ and see it as a
positive factor, whereas others will be frightened by pain.
In this person’s case it seems likely that too much walking
is being undertaken; she needs advice on smaller, more
frequent walks with attainable goals. For example, she
could be told to walk the length of the home every hour.
Knee flexion may be painful, in which case your role as
her physiotherapist is to identify the specific cause and
minimise or reduce it prior to active exercise. This might
consist of asking the patient to take her analgesia one
hour before commencing her exercises, or the application
of TENS or hydrotherapy as a supplement to exercise.
Her current exercise regimen needs to be modified.
She should be advised to go for regular, short walks and
gradually build up the length of time she walks for. She
needs exercises that will help strengthen her leg. These
should include quadriceps exercises, exercises for the
hamstrings, hip extensors and abductors, gastrocnemius
and anterior tibial muscles, and should be worked within
the permitted limits of the fracture rehabilitation. She
should only be given a few exercises at a time to
encourage compliance and help her grow in confidence.
These must be taught and explained clearly, written down
if possible, and the rationale behind them explained to
the patient. Patient compliance with exercise is, in
general, poor (Campbell et al. 2001) and the more you
can do to make home exercises simple and practical, the
An introduction to fractures Chapter 22
more success you will have in educating and rehabilitating
your patient. The patient should be advised to stop or
reduce the exercises if they are causing pain and seek
further advice.
Loss of knee flexion owing to callus may be impeding
soft tissue mobility. Pain, fear or muscle spasm might also
be causes of limited mobility; as she has more passive
than active range, something other than the joint is
limiting her movement. Your role is to identify the cause
and treat it accordingly. If there are no inflammatory
signs, a heat pack or massage may relieve spasm. The
brace limits flexion to 90 degrees so there is no reason
why you should not aim for 90 degrees at this time.
With regard to the oedema, an inefficient muscle
pump is a likely cause. She is not attaining heel strike but
is walking great distances; these will both exacerbate
dependent oedema. Little and often is the key, with
elevation during periods of rest, and a graduated increase
of walking distance. Massage might be used to relieve
oedema but can be time-consuming.
This person has a loss of limb girth on the affected
side. This will be a result of disuse atrophy. Decreased
limb girth is not as important as muscle function but may
be distressing to the patient; reassure her that function
will come first, then bulk. While it is not a true reflection
of quadriceps girth or strength, it does give the person
something specific to aim for.
Loss of accessory movement needs to be addressed in
the treatment plan, for example to the small joints of the
foot and mid-tarsal joints. The loss of accessory motion at
the patello-femoral joint should also be addressed; the
function of this joint cannot, and should not, be isolated
from the function of the knee joint itself. It is relatively
easy to identify immediate problems, but unfortunately
this alone is insufficient; you also need to be aware of
potential or longer-term complications.
POTENTIAL AND LONG-TERM PROBLEMS:
THE BIGGER PICTURE
 Adaptive shortening of the Achilles tendon leading to
permanent soft tissue contracture may occur if her
gait is not corrected as a consequence of her not
attaining heel strike. She currently does not have any
soft-tissue contracture as her measurements are full.
 Encourage her to walk shorter distances with a normal
gait.
 Check that her pain is being controlled adequately so
that she is not afraid to attain heel strike.
 Explain this to the patient so that she can take an
active role in her own rehabilitation.
 Make sure that a potential problem does not become
a real one.
 Fixed flexion deformity of the knee joint is also a
possibility if the importance of attaining full knee
extension is not explained to the patient.
521
 Tidy’s physiotherapy
Continued
 Remember that the hip joint is also involved and
should not be forgotten when planning rehabilitation
and providing exercises for the patient.
 Fibrous adhesions may occur if oedema is allowed to
‘Improvement’ (%)
organise.
 Retro-patellar adhesions may form as a result of
immobility of the knee’s expansive synovial membrane
and might become a cause of stiffness. The likelihood
of this happening might be reduced by isometric
contractions of the quadriceps and articularis genus
muscle whose task it is to retract the synovium of the
knee joint (Ahmad 1975).
 Degeneration of hyaline articular cartilage occurs if a
joint is not subjected to movement. The patient
should be encouraged to undertake general mobility
and exercise little and often.
 Generalised osteopaenia, or a reduction in bone
mineral density, may result if weight is not placed
through the limb. The see-saw needs careful
consideration here – see earlier in this chapter.
TREATMENT PLAN
 The patient must become effectively involved in the
management of her condition.
 Commence partial weight-bearing gait and progress
within protocol guidelines.
 Re-educate normal gait, i.e. heel strike.
 Mobility of all unaffected joints must be maintained
during the period of immobilisation.
 Regain movement and function to normal. This is
person-specific and full function might not be
attained until removal of the intramedullary nail in
one or two years’ time.
 Draw up a thorough and fully understood home
exercise programme which can be monitored and
progressed as needed. It is better to teach two
exercises well and have the patient thoroughly
understand them than teach ten exercises that are too
complex and confusing to the patient.
 Strengthen appropriate muscles dependent upon your
assessment findings. This may include exercises for
shoulders and the upper limb, as long use of elbow
crutches can cause pain in the wrists and shoulders.
This should not be overlooked.
 Progress to full weight-bearing within rehabilitation
guidelines; check any protocols and specific guidelines.
OVERALL PROGRESS AND DISCHARGE
Study the simplified graph in Figure 22.26. If we plot a
hypothetical ‘improvement versus time’ graph, the student
might hope for this pattern. (‘Improvement’ may mean
different things to different people. For purposes of clarity
it has been shown as a single item.) If this were the case,
recovery could always be predicted, all patients could use
the same treatment regimen, one assessment would be
sufficient, a discharge date could be predicted many
522
100
75
50
25
0
0 1 2 3 4 5 6 7
Treatment time (weeks)
Figure 22.26  A hypothetical improvement chart.
weeks in advance and undergraduate training would
take about a month! Unfortunately, this is not the case.
It is more likely that you will see a pattern of peaks,
troughs and plateaus, with a general trend towards
recovery. The overall shape of the real improvement curve
displays the gradual attainment of a plateau in
improvement.
This pattern of recovery is common: the patient may
gain ten degrees of knee flexion per week for the first
three weeks of treatment, then improvements will slow
to the point where it takes a further three weeks to
attain an additional five degrees. This presents the
physiotherapist with a constantly changeable situation
– which is one of the reasons why the profession is
so stimulating. It also poses the problem of when to
discharge the patient. The final decision must be a
mutually agreed decision between physiotherapist and
patient, and it is at this point that previously-agreed
goals are essential. It may be the case that 95%
‘improvement’ is the maximum possible improvement
attainable while the intramedullary nail remains in situ.
For example, there may be some residual discomfort
on running or squatting. Experienced physiotherapists
will be able to integrate their knowledge of anatomy,
physiology and biomechanics and explain to the patient
that now is the time for discharge and that the further
5% will occur following implant removal. Without a
sound prior assessment and formulation of goals,
appropriate patient discharge may be jeopardised,
resulting in discharge that is too early or treatments that
become repetitive, non-adaptive and inappropriate. The
advantage of physiotherapists being autonomous
practitioners is that with a little thought and a sound
initial assessment one can avoid the situation where the
patient is seen ‘twice a week for eight weeks’ with no
change in treatment or progression. The patient and
physiotherapist ‘own’ the process.

ACKNOWLEDGEMENTS
With thanks to Grit Soboll, Communications Manager Orthofix Srl; Dania Sorio, Customer Service International
Orthofix Srl; and the Association of Orthopaedic Chartered Physiotherapists Executive Committee.
FURTHER READING
Association of Orthopaedic Chartered
Physiotherapists. Physiotherapy
Guidelines of Good Practice in
Orthopaedics, www.aocp.co.uk.
Atkinson, K., Coutts, F., Hassenkamp,
A.M., 1999. Physiotherapy in
Orthopaedics – A Problem Solving
Approach. Churchill Livingstone,
Edinburgh.
Barker, K.L., Lamb, S.E., Simpson, A.H.,
2004. Functional recovery in
patients with nonunion treated with
the Ilizarov technique. J Bone Joint
Surg Br 860B, 81–85.
REFERENCES
Adams, C.I., Keating, J.F., Court-Brown,
C.M., 2001. Cigarette smoking and
open tibial fractures. Injury 32 (1),
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Ahmad, I., 1975. Articular muscle of
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 Chapter
Joint arthroplasty
Ann Price
INTRODUCTION
There is no ‘typical’ patient who is appropriate for a joint
arthroplasty. As with all modern medicine, a decision has
to be made which balances the risks of surgery against the
potential improvements. Patient age per se is no longer an
acceptable clinical decision-making tool (Brander et al.
1997). Generally, the surgical team promote conservative
treatments and optimisation of health until pain or disa-
bility is severe enough to cause a significant impact on the
person’s quality of life, where surgery would make things
significantly better or prevent a major deterioration.
Thus, successful modern joint replacements are based
on appropriate patient selection, selection of the appro­
priate implant, specific surgical technique and expertise,
and multi-disciplinary patient preparation and rehabilita-
tion. Nonetheless an artificial joint is not as efficient as its
organic counterpart: it does not repair itself and does not
absorb the stresses and strains of daily life as an organic
joint can.
UPPER LIMB ARTHROPLASTY
There are prostheses available for every joint in the upper
limb. Elbow, wrist and finger arthroplasties are performed
mainly for patients with rheumatoid arthritis, although
metacarpophalangeal (MCP) and proximal interphalan-
geal (PIP) joints are now being developed for patients
with osteoarthritis (OA) and following trauma. The car-
pometacarpal joint of the thumb is the most common
joint replacement for OA. There are also prostheses avail-
able to replace the ulnar head and the radial head; these
are normally used for reconstruction following difficult
forearm and elbow fractures.
23 
SHOULDER ARTHROPLASTY
Initially developed for the reconstruction of severe proxi-
mal humerus fractures, proximal humeral arthroplasty
was also used for people suffering from OA, with sur­
prisingly good results. In 1973, Neer redesigned the
humeral component and added a glenoid to make the
first unconstrained total shoulder arthroplasty. The basis
of the design was to produce as near to an anatomical
replacement as possible – the principle followed in most
modern prostheses (Neer et al. 1982).
There are many factors influencing the outcome of
shoulder arthroplasty (Iannotti and Williams 1998; see
Table 23.1) that physiotherapists need to know about
so that realistic rehabilitation goals can be set. Therefore,
good communication with the surgical team is very
important.
Primary OA is the indication for total shoulder arthro-
plasty from which the best results can be expected. The
result is dependent on the severity of the degenerative
changes that have taken place prior to surgery. For patients
who have primary OA without gross soft-tissue damage or
loss of bone, a near-normal range of movement and
strength can be expected: patients who start off with
rotator cuff disease or glenoid erosion should have less
high expectations.
For total shoulder arthroplasty, the most common
surgical approach is known as the ‘deltopectoral approach’.
The incision passes between the deltoid and pectoralis
major, and access to the shoulder joint is via the sub­
scapularis muscle and the anterior part of the capsule.
Thus, the subscapularis muscle is the only active structure
which will need to be protected in the early postoperative
period.
Table 23.2 shows a typical postoperative protocol;
however, these will vary depending upon the surgeon’s
525
 Tidy’s physiotherapy

Table 23.1  Factors affecting outcome of problematic Table 23.2  Example of postoperative routine
shoulder reconstruction following primary total shoulder arthroplasty for
osteoarthritis
Pathology
Day 1
Rotator cuff disease
Glenoid erosion bone loss Usual postoperative check, maintenance of range of
Humeral bone loss movement in hand and wrist
Bone loss
Bone density Day 2

Surgical technique Assisted active flexion and abduction, first by

physiotherapist followed by teaching patient-assisted
Prosthetic placement active of same movements using pulleys and exercise
Prosthetic–cement–bone interface stick
Soft-tissue balancing Patient is taught to do exercises x 4 daily

Prosthetic design Day 3 to 3 weeks

Size selection
Glenoid
Humeral head
Humeral stem
Offsets
Material properties
Rehabilitation programme
Range of motion
Strength
Stability
preference, any intra-operative changes to the procedure,
patient factors and their response. As always, the postop-
erative regimen must be agreed between the surgeon and
the physiotherapy team.
People with rheumatoid arthritis (RA) who undergo
shoulder arthroplasty are likely to have a number of the
adverse pathological factors (Table 23.1). The expected
results will depend on how many, and how severe, they
are, so the results are generally not as good as in OA
patients. The surgical approach and basic postoperative
management are the same.
In advanced disease (either OA or RA type) it is
not always possible to insert a glenoid component – it is
not possible to attach the glenoid component securely
enough if there is gross bone loss around the glenoid
fossa. Also, if there is a lack of rotator cuff function, the
humeral head will ‘rock’ the glenoid component, causing
loosening. The problem of glenoid fixation is one
of the ongoing dilemmas in shoulder arthroplasty
(Figure 23.1 and Figure 23.2).
Following a complex fracture it is normally a hemi-
arthroplasty that is performed, as the glenoid is usually
intact. The operation can be performed either as the
primary treatment for the fracture or later as a secondary
procedure (the results are better if it is performed in the
acute phase). Frequently, the tuberosities are disrupted
Continue with exercises as above and add extension,
internal rotation and lateral rotation to 30 degrees,
with the arm by the side. Abduction should always be
with the arm in neutral as the combined movement of
abduction and lateral rotation should not be attempted
until 3 weeks post-operation
The patient can progress from assisted active to active
movement as able. Once the person is comfortable he
or she may begin to use the arm for self-care activities
within the limits of pain and strength
3 weeks to 6 weeks
The patient should now have discarded the sling
completely during the day and should be progressing
from assisted active to active movement. The
physiotherapist will be showing appropriate ways to
do this
Active external rotation can be progressed beyond 30
degrees but stretching should still be avoided
6 weeks to 3 months
Progressive strengthening exercises in all ranges should
be encouraged according to the patient’s individual
capabilities. Rotator cuff strengthening should be
emphasised, using a progressive system such as
Theraband
3 months onwards
Many patients are discharged from treatment but should
be encouraged to continue with strengthening
exercises until optimum function has been achieved
giving the surgeon the additional challenge of restoring
normal anatomical alignment and cuff attachment with
secure fixation, thus allowing early rehabilitation. The
physiotherapy programme should be individualised,
taking into account any soft tissue trauma that will have
occurred at the time of injury.

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 Joint arthroplasty Chapter 23

Figure 23.2  Shoulder replacement showing humeral and

glenoid components and the appearance on X-ray.
(Reproduced by kind permission of Adam C. Gaines.)
C

Figure 23.1  (a) The global shoulder implant. (b) Sketch to

demonstrate the different heights of humeral head available.
(c) Sketch to show how the glenoid component is attached
to the glenoid fossa. (Reproduced by kind permission of De Puy
Orthopaedics Inc., IN, USA.)

527
 Tidy’s physiotherapy

TOTAL ELBOW ARTHROPLASTY

Elbow joint replacement is a more recent and much less

common operation. Although the number performed
remains small, it is regarded as a well-established surgical
procedure. It is performed usually within specialist ortho-
paedic centres for patients with marked degenerative
changes predominantly from RA, but also from OA or
trauma. Usually, all conservative management strategies
have failed leaving the patient with significant pain, dis-
ability and a poor quality of life.
The joint consists of two metal stems cemented into the
humerus and ulna, joined by a metal and plastic hinge.
The postoperative regime depends on the surgeon’s prefer- Figure 23.3  The hands of a person with rheumatoid arthritis
ence; some patients are splinted for a few weeks prior to showing the common deformities of ulnar drift and
subluxation of the metacarpophalangeal joints.
mobilisation. Normal function usually starts to resume
after 12 weeks. There will always be a carrying-weight
restriction on people with a total elbow arthroplasty.

THE HAND

RA can affect any joint in the body, but it is particularly

devastating to the complex collection of joints and intri-
cate soft tissues that make up the hand (Figure 23.3). Note
in Figure 23.3 the ulnar deviation of the fingers and the
more functionally debilitating deformity of the volar sub-
luxation of the metacarpal heads that robs the flexor
tendons of a proportion of their power, thus weakening
grip. The multi-disciplinary team (MDT) within specialist
hand units assess, surgically treat and rehabilitate patients
to regain hand function.
Figure 23.4  Insertion of a Swanson silastic metacarpophalangeal
flexible implant. (Reproduced courtesy of Wright Medical Inc.)

Key point

A principal role of the upper limb is to allow for maximum

use of the hand. Without a functioning hand the rest of
the upper limb becomes mainly a component of balance. As well as excising the destroyed joint surfaces and
inserting the flexible hinge, the surgeon must release and
rebalance the soft tissues crossing the joint if function is
to be restored.
The most common surgical procedure is the replace-
ment of the MCP joint by a silastic flexible hinge (Figure
23.4), developed by Swanson. A flexible implant arthro- Key point
plasty is different in principle from other joint arthroplast-
ies in that the implant acts as an inert flexible spacer, Swanson devised an equation to explain the process:
which is quickly surrounded by a layer of synovial tissue. bone resection + implant + encapsulation = new joint
The new tissue remains in contact with the implant and (Swanson et al. 1978).
surrounding this a stronger capsule develops.

528

Figure 23.5  (a) Dynamic extension splint (outrigger) in the
resting position. (b) Flexion at the MCP joints against the
resistance of the elastic bands.
Postoperatively, the short-term aims are:
• to achieve a functional arc of movement;
• to protect soft tissue repairs;
• to prevent further deformity at the affected joint and
the development of secondary deformities/
pathological change in the related musculoskeletal
system;
• to strengthen weak muscles;
• to re-educate function;
• to teach specific joint protection techniques.
These aims are achieved by early controlled movement,
which stimulates the formation of a strong, but flexible,
capsule around the implant. The most common way of
Joint arthroplasty Chapter 23
Figure 23.6  Splint to protect against recurrence of ulnar
drift. Protection is particularly important in strong gripping
activities.
controlling the movement is by the use of a dynamic
extension splint (DES), often referred to as an ‘outrigger’
(Figure 23.5), although in recent years static splinting
regimes have also been developed (Figure 23.6).
In the longer term, functional aims are achieved by
strengthening exercises, re-education of pulp–pulp pinch
and education in joint protection techniques.
When treating RA patients following surgery, always
remember that they have a systemic disease and postop-
erative regimens often need to be individually tailored.
Other upper limb arthroplasties are shown in Figures
23.7–23.10, which show photographs of the radial head,
wrist and finger, and trapezium arthoplasty photographs
and X-rays.
529
 Tidy’s physiotherapy

A B

Figure 23.7  Radial head arthroplasty and the appearance on X-ray. (Reproduced by kind permission of Adam C. Gaines, Wright
Medical Technology, TN, USA.)

A B

Figure 23.8  Wrist joint arthroplasty and the appearance on X-ray. (Reproduced by kind permission of Adam C. Gaines, Wright Medical
Technology, TN, USA.)

530
 Joint arthroplasty Chapter 23

Figure 23.9  Swanson finger replacement and the appearance on X-ray. (Reproduced by kind permission of Adam C. Gaines, Wright
Medical Technology, TN, USA.)

Key point

Lower limb joint replacement began in the 1950s. Sir

John Charnley refined and researched the unconstrained
low-friction hip arthroplasty that today is the gold
standard against which all other joint arthroplasty is
compared. Nowadays, the National Joint Registry for
England and Wales monitors the performance of hip,
knee and ankle replacements (www.njrcentre.org.uk).

Hip joint replacement is a major, yet commonplace,

orthopaedic procedure. The main pathologies that lead to
Figure 23.10  Trapezium replacement. (Reproduced by kind replacement surgery are OA, RA, congenital dislocation of
permission of Adam C. Gaines, Wright Medical Technology, TN, USA.) the hip, trauma (acute or longstanding), avascular necrosis
of the femoral head and infection. Revision surgery with
bone grafting is becoming more commonplace (both for
LOWER LIMB ARTHROPLASTY early and late failure) and specialist centres offer ever more
complex procedures including complex hip reconstruction
and the use of custom made implants.
The aims of lower limb joint replacement are: These pathologies and their respective drug therapies
• to relieve pain; can lead to varying bone structure that the surgeon has to
• to improve the range of motion at the joint; allow for at operation. For example, in the rheumatoid
• to improve the functional ability of the individual; joint the bone tends to be ‘soft’, whereas if the patient has
• to improve the person’s quality of life; had previous trauma or surgery (e.g. femur or upper
• to prevent further deformity. femoral osteotomy) then the bone is more ‘hard’. Thus,

531
 Tidy’s physiotherapy
within the generalisation that tends to occur with a known
procedure with a standardised rehabilitation protocol,
individualised care is essential to achieve optimum success
for the patient.
Modern implants aim, as far as possible, to replicate
the surfaces of the joint to be replaced. Experience has
shown that failure to fully understand joint motion and
to engineer components capable of tolerating the complex
interplay of forces generated by muscle pull (a three-
dimensional effect), ligaments, acceleration, deceleration,
weight and gravity will result in implant failure, pain
and disability. There has also been much research into
materials that are biologically inert, hard-wearing and
with minimum coefficient of friction. Today, this has led
to the use of components manufactured from metal alloys,
high-density polyethylene and ceramics. Fixation of the
components within the bone is, again, a complex issue,
but most success is through pressurised cementing tech-
niques or the use of hydroxyapatite-coated implants that
enable a fibro-osseous fixation to develop as part of the
bone healing process.
Although a very small percent age of patients will fail
within the first year from recurrent dislocation or infec-
tion, an increasing number of patients are now requiring
revision surgery owing to implant failure from wear over
time. The expected life of a joint replacement should be
10–15 years, with many hip replacements lasting longer
than 20 years. The main factors determining implant life
are surgical skill, bodyweight, lifestyle demands and levels
of high-impact stresses through the joint.
Primary modular metal and plastic hip replacements
are still very commonplace (separate metal alloy stem,
neck and ball and polyethylene socket) (Figure 23.11),
Acetabulum reamed out
to accept a cemented
plastic acetabular
component
Metal femoral component
(ceramic heads now also
in use)
A B
Figure 23.11  Total hip replacement. (Reproduced by kind permission of Medical Models Ltd, UK.)
532
although with the new materials available surgeons now
have more choice, enabling a more customised implant.
A variety of techniques are also used to surgically approach
the hip that can impact on early rehabilitation goals.
The relatively recent development of the metal on metal
hip resurfacing procedure has proved popular with the
younger, active patient, although the British Orthopaedic
Association is currently advising patients to have regular
follow-up as there has been a small, but significant, pro-
portion of patients developing a reaction to potential
microscopic metal debris accumulation.
Many objective assessments have been devised to assist
with patient selection, particularly for the hip and knee,
in order to quantify the severity of a patient’s problem and
general practitioners (GPs)/extended-scope practitioners
may use a score threshold for referral to an orthopaedic
surgeon. Until then, most patients will have had drug
therapy, minor procedures where indicated (particularly in
the knee) and physiotherapy, including self-management
programmes. Apart from therapeutic arthroscopy, joint
replacement (sometimes partial replacement in the knee)
is the only option that will allow a return to an improved
quality of life that is, on the whole, pain-free with good
function. Ankle replacement is less common and very
dependent upon accurate assessment by the surgeon, par-
ticularly of the hind foot, and may require additional
pre-replacement surgery.
Factors taken into account by the surgeon when listing
a patient for surgery include:
• severity of disease – onset, progress, other joints
affected, investigations;
• pain and sleep disturbance;
• disability – effect on work and lifestyle;
 Joint arthroplasty Chapter 23

• age – given the life expectancy of the implants;
• weight – keeping the stresses through the implant as
low as possible;
• emotional stability – outcome less successful after a
personal shock or bereavement;
• cognitive function.
Once listed for joint replacement, any underlying medical
condition must be optimised prior to surgery via the pre-
operative clinic. The anaesthetist usually reviews patients
with significant medical history, decides the level of anaes-
thetic risk and, if possible, plans appropriate anaesthesia
with the patient. General anaesthesia is less common –
spinal anaesthesia with effective pain management enables
more rapid mobilisation and helps to decrease the risk of
deep vein thrombosis (DVT).
Pre-operatively the physiotherapist, along with the
occupational therapist and the nurse, should prepare the
patient for the procedure and help set their expectations
for discharge and recuperation – commonly through
information and education groups, although an individ-
ual session may be required by patients with complex
needs.
Complications of joint replacement in the short-term
are likely to be secondary to having a surgical intervention:
DVT, pulmonary embolism, wound infection, heart dys-
function, paralytic ileus and bleeding. Specific early ortho-
paedic complications include dislocation, deep infection,
neuropraxia and haematoma.
In the long-term the complications include scar sensitiv-
ity, dislocation, joint infection and implant loosening.
femoral components or (2) hammering the components
into place. The hip is trialled for stability and leg length
before definitive placement and closure. The gluteal
tendons are reattached to the greater trochanter in the
posterior approach and the greater trochanter reattached
using a specialised wiring technique in the lateral approach
(Figure 23.12). Soft tissues are closed in layers. Drains
may or may not be used and dressings are applied. The
patient is roused and transferred to the recovery ward.
Once stable the patient returns to the ward. Pain relief is
vital for early rehabilitation and safe swift discharge –
to the care of a hospital at home team where available –
at day 2–4.
These differences usually dictate rehabilitation proto-
cols with the osteotomy usually requiring protection for a
longer period. Always follow the surgeon’s protocol unless
informed otherwise or there is a change in the patient’s
condition.
Complications of hip replacement
All surgery is not without potential complications. Hip
replacement surgery is major surgery and the general
major risks apply. Specifically in hip replacement compli-
cations can be intra-operative, early postoperative and
late. During surgery there is risk of nerve and blood
vessel damage. Early postoperative complications include
dislocation (3.9%), embolism (0.9%) and deep infec­
tion (0.2%). See Table 23.3 for early complications
and preventative strategies. Late complications, i.e. after
six months, include aseptic loosening (4.3%), recurrent
dislocation (1.1%) and deep infection (0.3%).

TOTAL HIP REPLACEMENT

The hip is the largest and deepest joint in the body. It takes
the form of a multiaxial spheroidal joint with three degrees
of freedom of movement with high levels of congruency
(stability and surface area for stress transmission) and
extensive range of movement.
Key point
It is vital for the physiotherapist to understand the
procedure that the person is about to undergo, and the
likely routine to be followed. Watching the operation at
least once is useful.

The implant
Where a small femoral head is used the procedure is
known as the ‘low-friction arthroplasty’ (LFA), as designed
by Sir John Charnley.
The hip joint can be approached through a variety of
incisions: commonly a posterior approach requiring
detachment of gluteus medius and minimus or a lateral
approach requiring osteotomy of the greater trochanter.
The femoral neck is then divided, the joint dislocated and
the head removed. The femoral canal and acetabulum
are reamed down to fresh, bleeding bone and prepared
for component implantation. Cavity size depends on the
fixation technique. Component fixation is achieved either
by (1) using pressurised cement (that can be available
impregnated with antibiotics) to fix both socket and Figure 23.12  X-ray of a hip replacement.

533
 Tidy’s physiotherapy

Table 23.3  Complications of hip arthroplasty

Complication Caused by Solution

Anaesthetic risk Anaesthesia type Careful preoperative anaesthetic

(chest, heart) assessment
Appropriate physiotherapy assessment
and treatment as required

Infection Open surgery Laminar flow theatres, exhaust suits,

prophylactic antibiotics post-
operation [24 hrs]

Dislocation Difficult surgery, poor surgical technique, complex
case, inherently unstable, e.g. if patient has had
a cerebrovascular accident (CVA), the risk of
subsequent dislocation may be higher owing to
decreased muscular stability at the hip joint
Abduction wedge, no adduction/flex
beyond 90 degrees, special
restraining device attached to socket
may be used in cases of previous
dislocation

DVT/PE Pelvic surgery, immobility Prophylactic anticoagulants – sub cut

Damage to the blood vessels during surgery or oral, early mobilisation, anti
embolic stockings

Anaemia Blood loss during/post surgery Transfuse if haemoglobin (Hb) below 8

or patient symptomatic (check
hospital protocol)

Swollen ankle Ineffective muscle pump Reassure, walk little and often,
frequent rest in bed, ankle exercises,
compression stockings may help

Arm/hand pain Crutch walking Time

Neck pain Neck trauma due to neck being held in an extended Time
position during the intubation [GA]

Stiffness after Inflammatory exudate builds at rest Reassure, walk little and often
immobility

The immediate postoperative period
The patient will have an abduction pillow in place to
protect the new joint. Physiotherapy includes active exer-
cises for feet and ankles, isometric hip and knee contrac-
tions of all muscle groups, chest physiotherapy as necessary,
advice on positioning and mobility in the bed.
As soon as the patient is assessed as ready to mobilise,
i.e. is orientated, has satisfactory observations, pain is con-
trolled and motor control is established (for those patients
with epidural/peripheral nerve blocks), the patient is
assisted out of bed initially by two staff and instructed in
movement techniques that prevent excess hip flexion,
adduction and medial rotation, and safe mobilisation –
usually partial weight-bearing using an appropriate aid (a
walking frame or a pair of elbow crutches).
Initially, the patient will stand out of bed and take a few
steps with crutches or another appropriate aid (usually
partial weight-bearing). Walking distance is progressed
daily until the patient is walking independently with
crutches or a frame.
Routines vary, but patients usually commence sitting at
1–2 days (no adduction or flexion beyond 90 degrees),
with stair practice before discharge if needed. Usually,
patients remain on crutches for six weeks, at which time
they progress to sticks, then full weight-bearing.
‘Dos’ and ‘don’ts’ must be stressed to the patient
(Table 23.4) and an educational booklet provided as a
reminder. It is also important that occupational therapists
and other members of the MDT see the patient.
Suggested rehabilitation protocol
following total hip replacement
Key point
All activity should be documented to the Chartered Society
of Physiotherapist’s (CSP) documentation standards.
MDT care pathways can also be completed – these
aid effective communication between all staff, ensure all
goals are met and allow for ease of service audit.

534

Table 23.4  Dos and don’ts following total
hip replacement
Follow your hospital instructions but generally
Don’t
• Do not pick up any objects from the floor or reach into
low cupboards. Use a reaching aid if possible.
• Do not cross your legs.
• Do not overbend your hip.
• Do not sit on low chairs, low stools, or low toilets.
• Avoid sitting on chairs without arms. You may need to
use the arms of the chair to help you to rise.
• When sitting, standing or lying down, try to keep your
foot pointing forwards, not rolling inwards.
• Move to the edge of the chair before you stand up
(keep your operated leg fairly straight at the knee).
• Do not lie either side for 6 weeks.
Do
• Take your time when you get home.
• Rotate your activities, i.e. lie for short periods if you
are very tired, walk little and often, sit for short
periods.
• Set yourself small achievable targets with your walking,
using your crutches as instructed.
• Pace yourself.
• Remember that you will get good days and bad days.
• It may be useful for you to keep a progress diary so
that you can reflect back on your progress.
Day 1
There should be assessment by the physiotherapist of neu-
rovasculomotor and respiratory systems. Active exercises
for circulation and static exercises for muscle tone around
the hip can be started, along with deep-breathing exer-
cises. Notes and X-rays should be studied as soon as avail-
able. Note the surgical approach and any non-standard
procedure. Mobilisation may commence, according to the
surgeon’s preference.
Day 2
Functional rehabilitation continues towards achievement
of safe, independent mobility with walking aids. The phys-
iotherapist assists and ensures hip protection at all times.
Day 3 onwards
Mobility is progressed on a daily basis. A stair assessment
should be completed if possible. Advice is given prior to
discharge concerning expected levels of activity until clinic
review. No other specific exercises are required during this
period. Regular and gradually extended walking practice
is necessary in/outdoors. Ensure the emphasis is on hip
Joint arthroplasty Chapter 23
protection and recovery (effective capsular scarring). There
are three simple, golden rules:
• do not overbend the hip (flex beyond a right-angle);
• do not cross the leg over the midline (adduct beyond
neutral);
• do not twist in either standing or sitting.
These rules apply for six weeks in all cases. If the tro-
chanter is to be protected then the rules apply for longer
and it is generally accepted that the patient can return to
normal activities at three months.
After discharge
If the soft-tissue approach was used the patient may be
issued with sticks and advised to gradually increase weight-
bearing over the next six weeks. If the transtrochanteric
approach was used then the site of bony union must be
protected for 12 weeks.
A long-term rule is to avoid high-impact activities,
as sudden high pressures cause the most wear to the
plastic.
The patient may telephone with queries following dis-
charge but must contact the GP or attend the accident and
emergency department with any sudden significant pain
or swelling.
Further physiotherapy/exercise may be required follow-
ing clinic review and the appropriate referral can be made.
Some centres offer outpatient rehabilitation programmes.
Rehabilitation following  
revision surgery
There is frequently augmentation of the acetabular and
femoral bone required using bone grafting techniques
and, in some cases, the use of screws and mesh to hold
the graft in place. The graft acts as scaffolding for migrating
osteocytes which then lay down new bone and incorpo-
rate the graft.
Depending on the reason for revision (commonly wear
and loosening, fracture, infection, dislocation) and the
complexity of the procedure, the physiotherapy as out-
lined above is modified appropriately in the light of the
surgeon’s instructions.
TOTAL KNEE REPLACEMENT
The knee is a complex joint whose stability is dependent
on extra-articular ligaments, fascia and muscular control.
Knee problems usually present with gross biomechanical
deformity requiring soft tissue release at operation in
order to regain biomechanical alignment and normal bal-
anced soft tissue lengths.
535
 Tidy’s physiotherapy

The implant
The unconstrained implant uses metal-alloy components
over the distal femur and proximal tibia. A high-molecular-
weight (high-density) polyethylene bearing is inserted
between . The patella may be resurfaced with a metal-alloy
articulating button if necessary.
In the case of a severely deformed joint and, more
commonly, in revision procedures, physical constraint to
movement can be achieved by use of long-stemmed linked
implants. The risk of failure secondary to its inability to
move freely is less likely in the patient with low functional
demand or is an accepted risk when surgical options are
compromised.

The operation
Commonly, a tourniquet is applied, the leg is exsanguin-
ated and the tourniquet tightened for a timed period. With
the knee in flexion the surgical approach is, on the whole,
by anterior skin incision followed by medial parapatellar
incision through quadriceps expansion. The patella is
reflected laterally and the joint exposed. Very rarely (and
seen more in revision surgery) the tibial tuberosity is sawn A
off with a large piece of anterior tibial bone to allow
improved access to the joint. Bone cuts and preparation
followed by component trial is carried out. The femoral
component is held in place by two short pegs into each
condyle and the tibial component by a large single peg
into the tibia. The pressurised cementing technique as
described previously for the hip replacement operation
can be used or uncemeted coated components hammered
into the bone. Closure of the joint is in layers. The patient
may or may not have drains inserted. A wool and crêpe
bandage is applied to control oedema and a backsplint
may be applied to maintain the knee in extension until
quadriceps function is regained (Figure 23.13).

Suggested rehabilitation protocol

following total knee replacement
The general postoperative physiotherapy is as previously
described for hip replacement, except that the emphasis is
on regaining quadriceps control. If the patient has had a
femoral block for pain relief, active quadriceps function
may take up to 24 hours to return. Mobilisation and the
start of the exercise programme may commence on days
1–2. The patient starts to walk with two crutches and is
full or partial weight-bearing for six weeks. Transfer on to
sticks is possible at any point during this time also. Exer- B
cises are prescribed according to the surgeon’s routine and
the physiotherapeutic assessment of the patient. The splint Figure 23.13a,b  Total knee replacements. (Reproduced
and bandage must be removed prior to physiotherapy. It courtesy of Wright Medical Technology, Inc.)
is vital that exercises be practised very regularly – little and
often, almost hourly at first, progressing to several times

536
 Joint arthroplasty Chapter 23

per day of differing exercises. It is paramount that quadri-

ceps function be regained and therefore the control and
protection of the joint established using simple closed-
chain quadriceps and slow stretch knee flexion exercises.
It is important to provide the patient with a written exer-
cise programme tailored to the individual’s needs that can
be adjusted and reviewed as progress continues. Flexion is
usually hampered by pain, fear, bruising and swelling.
Physiotherapy should therefore include help in the control
of these symptoms by reassurance, coordination with
analgesia, cryotherapy and careful assisted flexion. The
patient can be instructed in the safe application of ice at
home. Do not forget that full extension is a vital compo-
nent of knee joint function.
Length of hospital stay is usually 3–4 days, by which
time the patient should be functionally independent and
Figure 23.14  Ankle joint replacement. (Reproduced by kind
progressing with rehabilitation. Ideally, the range of move-
permission of De Puy Orthopaedics Inc., IN, USA.)
ment should be 0–90 degrees with active knee control. On
discharge most patients are referred for outpatient physi-
otherapy to review progress, continue with assisted exer-
cises or start more advanced rehabilitation. components being hammered into place. The tissues are
closed in layers and compression dressing applied. The
patient is roused and nursed as described previously and
the limb is maintained in elevation.
TOTAL ANKLE REPLACEMENT
Suggested rehabilitation protocol
Total ankle replacement is the ‘youngest’ of the lower limb
following total ankle replacement
joint replacements. Attempts were made in the 1970s but
were unsuccessful. There has now been success with a Postoperative physiotherapy is as previously described for
semi-constrained implant; however, this success will hip and knee replacements, except that routine ankle exer-
depend on the health of the subtalar joint below it. Some- cises are avoided and toe exercises substituted. It may be
times (particularly in people with RA), the diseased sub- necessary for the physiotherapist to ensure dorsiflexion
talar joint is fused prior to the total ankle replacement to to a right-angle (plantigrade) and, where this is difficult,
give the optimum outcome. Also, in this anatomical to show the patient an appropriate stretch exercise with
region the integrity of the circulation is vital and great care a strap.
is taken in the selection of a patient in whom both circula- Mobilisation is usually on day 2 or 3 when the swelling
tion and skin can withstand the stress of operation and is controlled and the compression dressings removed,
support the demands of the healing process. according to the surgeon’s instructions. A protective knee-
The articular surfaces of the tibia and the talus are length plastic boot that can be removed for wound inspec-
replaced with metal alloy implants. The talar implant is tion can be fitted and the patient mobilised to partial
centrally ridged forward to back to accommodate the weight-bearing with elbow crutches for functional require-
sulcus on the inferior surface of the polyethylene bearing ments only (the leg is rested in elevation otherwise). Tech-
inserted between them (Figure 23.14). This allows for niques to manage stairs/steps/ramps are taught.
flexion and extension and decreases the risk of malleolar The length of stay is usually 3–4 days. The patient is
fracture by medial slip of the bearing. The surgical reviewed in the clinic at 2–3 weeks for removal of sutures
approach to the joint is via a 10-cm anterior ankle and the plastic boot. Exercises can be started at this point
incision. Care is taken to avoid the anterior tibial neurov- to facilitate rehabilitation, including Achilles tendon
ascular bundle. The bones are cut and prepared as previ- stretches, muscle strengthening and balance function.
ously described. The implant is usually uncemented; the Specific mobilisation of the ankle is avoided.

537
 Tidy’s physiotherapy
FURTHER READING
Atkinson, K., Coutts, F., Hassenkamp,
A.-M., 1999. Physiotherapy in
Orthopaedics: a Problem Solving
Approach. Churchill Livingstone,
Edinburgh.
Birch, A., Gwillian, L., 2000.
Rheumatoid arthritis and its effects
REFERENCES
Brander, V.A., Malhotra, S., Jet, J., et al.,
1997. Outcome of hip and knee
arthroplasty in persons aged 80 years
and older. Clin Orthop 345, 67–78.
Iannotti, J.P., Williams, G.R., 1998.
Total shoulder arthroplasty: factors
influencing prosthetic design. Ortho
Clinics N Am 29, 377–391.
Neer, C.S., Watson, K.C., Stanto, F.J.,
1982. Recent experience in total
538
on the hand. In: Salter, M.,
Cheshire, L. (Eds.), Hand
Therapy Principle and Practice.
Butterworth-Heinemann,
Oxford.
Simmen, B.R., Allieu, Y., Luch, A.,
et al., (Eds.), 2001. Hand
shoulder replacement. J Bone Joint
Surg 64A, 319–337.
Swanson, A.B., Swanson G de, G.,
Leonard, J., 1978. Postoperative
rehabilitation program in flexible
implant arthroplasty of the digits.
In: Hunter, J.M., Schneider, L.H.,
Mackin, E.J., et al., (Eds.),
Rehabilitation of the Hand. CV
Mosby, St Louis, pp. 477–481.
Arthroplasties. Martin Dunitz,
London.
Skirven, T.M., et al., 2011.
Rehabilitation of the hand and
upper extremity, 2-Volume set, sixth
ed. Mosby, Philadelphia.
Swanson, A.B., Swanson G de, G.,
DeHeer, D.H., 2000. Small joint
implant arthroplasty: 38 years of
research experience. In: Simmen,
B.R., Allieu, Y., Luch, A., et al.,
(Eds.), Hand Arthroplasties. Martin
Dunitz, London.
 Chapter
Physiotherapy management of Parkinson’s
and of older people
Bhanu Ramaswamy and Paula McCandless
INTRODUCTION
Physiotherapists working with older adults and people
diagnosed with Parkinson’s are required to have know­
ledge of core physiotherapy areas. Effective practice
depends on your ability to apply the knowledge appropri­
ately in context of the individual’s physical, psychological
and sociocultural status and need.
In this chapter, physiotherapy management of Parkin­
son’s and of older adults will be explored together;
however, Parkinson’s should not be regarded as a condi­
tion affecting only the older population. Dealing with
either population highlights vastly different needs and
solutions, yet the situations also offer fundamentally
similar challenges. These include working within an inter­
disciplinary environment; utilising skills that deal with
complex bio-psycho-social factors; applying knowledge
in managing a process of progression (usually deteriora­
tion); and relating changes to the ageing process, to a
neurological presentation, or to both. For these reasons,
the two topics have been integrated into one chapter.
Information has been integrated through the chapter
where evidence and practice can be transferred between
the two groups. If something is of particular relevance to
either the older adult population or to Parkinson’s, this
has been specified.
Finally, as the book aims to assist your development of
physiotherapy practice, the chapter focusses more on the
practical aspects of assessment and management than on
demography and pathology. All issues have signposts to
easily accessible information for you to pursue.
24 
Key point
Irrespective of a person’s condition or age, physiotherapy
has a role to play in enabling both health and well-
being-related lifestyle choices. This may be through
education, through the restoration of function,
maximising the potential of the person or by minimising
the impact of decline for people with a deteriorating
condition.
ABOUT AGEING
Ageing describes the process of growing old, with normal
ageing being considered a state that occurs without disease.
Worldwide populations are growing as human life expect­
ancy increases. The proportionate increase of older adult
numbers within the populations has been named ‘The
Greying of the Nations’. In light of this issue, over the last
20 years, various countries have supported research to
investigate their older populations so that they might esti­
mate and provide the resources required to maintain as
healthy a population as possible.
On average, the ‘older adult’ label spans a 20–30 year
period with an arbitrary division into three ages of ‘old’:
• between 60 and 75 years = young old;
• between 75 and 85 years = old;
• those older than 85 years are considered the frail
older population.
539
 Tidy’s physiotherapy

Table 24.1  Percentage of people aged over 60 years admitted to Northern General Hospital, Sheffield

Speciality Description 1999 2001 2003 2005 2007 2009

(% >60 years)

Cardiology 57 59.0 60.8 60.4 61.9 62.1

Cardiothoracics 57 58.9 62.4 66.3 59.5 68.8

General/chest medicine 60 64.5 65.2 75.4 67.7 56.2

Heart transplant 27 28.0 35.4 55.8 53.3 10.0

Nephrology 42 43.3 50.1 56.5 59.8 63.8

Orthopaedics 40 41.4 44.5 45.2 45.6 45.9

Plastic surgery 27 31.3 30.3 31.6 29.4 35.4

Spinal injuries 18 21.9 23.8 21.3 22.1 26.0

Vascular surgery 61 64.4 59.0 51.6 53.9 60.5

Average 37.54 37.49 40.1 41.11 43.12 46.88

The variations between the populations in each age

band require different approaches when considering
the physical, psychological and social needs of people
within the groups (DH 2001).
Thinking that the ageing population is only of concern
to physiotherapists specialising in older people is unreal­
istic. The percentage of people aged above 60 years admit­
ted to clinical specialities in a Sheffield hospital over a
ten-year period (Table 24.1) illustrates a pattern of overall
increase in the numbers of older people. It is important
that these people receive the same level of service and care
as anyone else, irrespective of age.
Recommended reading
• National Statistics Online at: http://
www.statistics.gov.uk/. This site provides information
such as population demographics across the UK,
changes in lifestyle choices, health and life
expectancy.
• The National Service Framework for Older People
(DH 2001). The Standards agreed for this 10 year
programme of action ensure fair, high quality,
integrated services for older people; support
independence and promote good health, respect,
dignity and fairness (http://www.dh.gov.uk/en/
Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_4003066).
• Reports on Global Action on Ageing at:
www.globalaging.org.
• The United Nations Programme on Ageing at: http://
www.un.org/esa/socdev/ageing/index.html.
ABOUT PARKINSON’S
Parkinson’s is a chronic, progressive neurodegenerative
disorder of the central nervous system; it is the most
common disorder of the basal ganglia and the second
most common neurodegenerative disorder in the UK
after Alzheimer’s disease (Jones and Playfer 2004). The
incidence increases with age and has no currently
known cure.
The condition was described first as ‘the shaking palsy’
in 1817 by Dr James Parkinson, whose clinical description
identified both the main motor symptoms and non-motor
symptoms (Tables 24.2 and 24.3; adapted from Jankovic
2008: 368). The main area of basal ganglia dysfunction
appears to stem from the loss of dopamine-producing
cells in the substantia nigra, causing difficulty in the initia­
tion of movement (internal cueing mechanism).
Symptoms differ from person to person and in the same
person over time. The presentation of these varied symp­
toms has led people in the UK affected by Parkinson’s
(those diagnosed, their families and their carers) to cam­
paign against the use of the term ‘disease’.
Tremor
The typical Parkinson’s rest tremor occurs at 4–6 Hz. It
begins unilaterally, described in the hand as a ‘pill rolling
tremor’ (resembling a pill being rolled between the thumb
and fingertips) and can occur in the feet, jaw, chin and
lips. It is distinct from ‘essential tremor’ and varies during
the course of the condition and within the Parkinson’s
population.

540
 Physiotherapy management of Parkinson’s and of older people
Table 24.2  Primary motor symptoms (TRAP) or
cardinal signs of Parkinson’s
Tremor (rest)
Rigidity
Akinesia (including bradykinesia)
Postural instability (loss of postural reflexes)
Clinical note
Parkinson’s is a neurodegenerative disorder characterised
by tremor, bradykinesia and postural instability (leaving
them at greater risk of falls than the general population),
and is associated with a number of non-motor features,
including cognitive impairment, neuropsychiatric signs
and symptoms, dysautomnia and sleep disorder (NICE
2006; Chaudhuri et al. 2007).
From the point of view of a physiotherapist, the
progressive symptoms of Parkinson’s can affect the
quality of life of the individual, their carers and/or their
relatives. Increasing impairment and disability results in a
reduced participation in societal roles. Speech impairment
can be particularly burdensome, increasing social
isolation; physical activity levels are reduced and cardiac
symptoms, such as heart rate variability and sympathetic
denervation of the heart, affecting the response to
mobility and exercise.
Rigidity
A form of hyper-tonicity causing stiffness or inflexibility
of the muscles from loss of normal reciprocal inhibition
– is thought to be a result of excessive excitation of alpha
motor neurones that are normally inhibited by the basal
ganglia. You may observe rigidity as reduced arm swing
during walking or reduced heel strike owing to rigidity in
the calf. Rigidity can cause pain and cramping, impover­
ished movement and added internal resistance when
undertaking exercise. It is described as:
• lead pipe rigidity – consistent resistance to
movement throughout the full joint range;
• cog-wheel rigidity – ‘jerky’, inconsistent resistance to
movement throughout joint range, occurring distally
(wrist and ankle) if an existing tremor interferes with
movement.
Akinesias
There are several forms of akinesias:
• Bradykinesia (slowness in movement performance
or loss of spontaneity of movement) – is the most
characteristic feature of Parkinson’s, although the
pathophysiology has not been fully identified.
Chapter 24
Table 24.3  Secondary motor and non-motor
symptoms
Secondary motor Freezing, shuffling gait, festination
symptoms of Dysarthria (motor speech disorder)
Parkinson’s Hypomimia (reduced facial
expression)
Dysphagia (difficulty swallowing)
Dystonia (movement disorder-spasms)
Sialorrhea (excessive secretion of
saliva)
Glabellar reflexes (blinking on
tapping of the forehead)
Micrographia (small handwriting)
Non-motor Autonomic dysfunction, cognitive
symptoms of neuro-behavioural abnormalities.
Parkinson’s Includes dementia, depression,
psychosis, impulse control disorder
(Weintraub 2010)
Sleep disorders, sexual problems
Anosmia (lack of smell)
Gastrointestinal dysfunction
Constipation
Urinary incontinence
Weight problems
Sensory abnormalities (paraesthesia,
pain)
(Adapted from Jankovic 2008.)
It is thought to result from a reduction in normal
motor cortex activity facilitated by a reduction in
dopaminergic function (dopamine deficiency levels).
The slowness may be demonstrated through difficulty
with planning, initiating, executing and performing
sequential and simultaneous tasks, and loss of fine
motor control. If there is a swallowing impairment,
presentations of bradykinesia might include drooling,
loss of spontaneous movements and gesturing.
• Hypokinesia – a decrease in amplitude may, for
example, account for lack of arm swing during
walking, loss of facial expression and reduced
blinking.
These forms of akinesia cause reduction in movement
range and velocity, making automatic and repetitive move­
ments difficult.
• Dyskinesias – are abnormal, involuntary movements
and often are a common side effect of medication.
They can become disabling, adding to the risk of
falls and injury.
Postural instability
Postural instability equates to the loss of postural reflexes
essential for normal movement and alongside freezing of
541
 Tidy’s physiotherapy
gait, is a major cause of falls and hip fractures in those
with Parkinson’s; it usually manifests in the later stages of
the condition. The ‘pull test’ of the Unified Parkinson’s
Disease Rating Scale (UPDRS) or ‘retropulsion test’ is used
to assess this clinical feature by pulling the person being
tested backwards or forwards by their shoulders (or hips),
and noting their response to displacement. An abnormal
response (positive postural instability) is identified if no
postural correction is observed or more than two steps
backwards are taken.
Combinations of TRAP (tremor, rigidity, akinesia, pos­
tural instability) can lead to secondary motor symptoms.
A classic one is the ‘Simian’ posture where the spinal
curvature results in a flattened lumbar lordosis, rounded
shoulders and a poking chin (hyperextended cervical
spine). The consequent forward flexed upper body results
in the ‘ape-like’ posture. Examples of secondary motor
and common non-motor symptoms are tabulated above
(Table 24.3).
Diagnosis
Currently, no reliable test exists for Parkinson’s so diagno­
sis is determined through the history and clinical signs of
at least two of the four cardinal motor symptoms described
earlier using the UK Brain Bank Criteria and investigations
(scans) (NICE 2006).
Parkinson’s is the most common presentation within a
collection of motor system disorders known as ‘Parkinson­
ism’ (Table 24.4). The various disorders can be identified
using positron emission tomography (PET) and structural
magnetic resonance imaging (MRI) scanning. They are
also referred to as ‘Parkinson’s Plus’ as they involve a wider
area of the nervous system than idiopathic Parkinson’s
(SIGN 2010: 11–13).
Medication is less effective or may have to be withdrawn
for people with Parkinson’s Plus syndromes, and the
course and presentation differs from those with ‘idio­
pathic’ Parkinson’s described in this chapter.
Clinical note
To minimise misdiagnosis and incorrect treatment
regimes, a person with Parkinson’s should be seen by a
specialist multi-disciplinary team, with the opportunity for
review by a specialist neurologist or geriatrician, and
referral to a Parkinson’s Nurse Specialist.
Aetiology and epidemiology
There are approximately 120,000 people with Parkinson’s
in the UK and an estimated 6.3 million worldwide.
The average age of onset is 60–65 years. The term ‘idio­
pathic’ is used when there is no known cause of the
542
Table 24.4  Parkinsonism or ‘Parkinson’s Plus’
syndromes
Primary Progressive supranuclear palsy
neurodegenerative (PSP)
disorder Multiple systems atrophy (MSA)
Cortico-basal degeneration (CBD)
Secondary Multiple cerebral infarction
neurodegenerative Drugs and environmental toxins
disorder Trauma from boxing
Parkinson’s, as no known single, universal causative factor
has yet been identified. Several theories exist – the most
common of which proposes Parkinson’s to result from
a variety of pathological processes in addition to influenc­
ing factors, such as the environment, the ageing process
and genetics.
Neuropathology
The ‘ascending hypothesis’ of idiopathic Parkinson’s con­
ceptualises a pathological progression from the lower
brainstem (pre-clinical stage) to the midbrain (substantia
nigra clinical stage) and cortex (end-stage) (Braak et al.
2003; Yanagisawa 2006). Extra-pyramidal system dysfunc­
tion leads to the loss of the internal ‘go’ setting, essential
for movement initiation that becomes evident after the
pre-clinical stage.
Pathologically, Parkinson’s is characterised by a reduc­
tion of neuromelanin cells in the brainstem, primarily
dopamine neurones in the substantia nigra, but also in the
corpus striatum (caudate nucleus and putamen). People
with Parkinson’s will have lost over 70% of dopamine-
producing cells before motor signs (TRAP) are visible. This
is thought to cause an inability to direct and control move­
ments (rigidity and loss of inhibition of tremor), while
increasing inhibition to the thalamus (bradykinesia). A
lack of inhibition mainly of the reticulospinal and vestibu­
lospinal pathways results in excessive contraction of pos­
tural muscles. The imbalance of inhibition and excitation
result in the classical clinical features of Parkinson’s.
Classification
Parkinson’s is classed in various ways. The most common
method is by severity according to the (modified) Hoehn
and Yahr scale (1967), categorising people along a con­
tinuum from asymmetry at Stage 1 to Stage 5 palliation.
Physiotherapy referrals usually occur when signs of poor
balance develop and possibly a fall from Stage 3 onwards.
MacMahon and Thomas (1998) have provided a clinical
staging classification, allowing for periods of deterioration
during illness, but regaining the ability on recovery. Details
of both these can be read in the Parkinson’s Professional
Guide (PDS 2007).
 Physiotherapy management of Parkinson’s and of older people Chapter 24

In light of evolving information regarding the pre-­ The importance of such classifications for physiothera­
clinical development of Parkinson’s, Stern et al. (2012) pists is evident when decision-making about progression
have proposed the following phases to reflect the progress and intervention have to be considered, and equipment
of the condition (Table 24.5). and support networks put into place.
A cluster analysis of presentation at diagnosis has pro­
vided detail according to a person’s age, cognitive state
(presence of dementia or not) and symptom dominance Recommended reading
(van Rooden et al. 2010). The four subtypes of Parkinson’s
are identified below. For more details about the demographics of Parkinson’s,
of diagnostic processes and of neuroanatomy, read the
• Early disease onset (25%) – longest duration until
following or look up information on the following
death, delay before falls or cognitive decline.
websites:
• Tremor dominant (31%) – same life expectancy, falls
• the National Institute for Health and Clinical
history and hallucinations as non-tremor dominant.
Excellence (NICE) Guidelines 35 – Parkinson’s disease:
• Non-tremor dominant (36%) – strong association Diagnosis and management in primary and secondary
with cognitive impairment (Lewy body pathology). care (2006) (http://www.nice.org.uk/nicemedia/
• Rapid disease progression without dementia (8%) live/10984/30088/30088.pdf);
– often tremulous onset in older people, early
• The Parkinson’s UK website (http://
depression, midline symptoms, increased mentation, www.parkinsons.org.uk/default.aspx). This site will
freezing and activities of daily living (ADL) sub- also give you a current Glossary of useful terms;
scores according to Part I and II of the UPDRS. utilising this will aid your knowledge and
understanding of choices for the management of
people affected by Parkinson’s;
Table 24.5  Phases of development in Parkinson’s • The European Parkinson’s Disease Association website
(Stern et al. 2012) (http://www.epda.eu.com/).
Phase 1 Pre-clinical PD PD-specific pathology
assumed to be present,
supported by molecular or The International Classification of
imaging markers, no clinical
signs and symptoms
Functioning, Disability and Health
Phase 2 Pre-motor PD Presence of early non-motor
The International Classification of Functioning, Disability
signs and symptoms due to and Health (ICF) (WHO 2001) offers a model for consid­
extranigral PD pathology eration of multiple impairments, relating them to domains
that guide assessment, goal-setting and treatment-planning
Phase 3 Motor PD PD pathology involves (Figure 24.1).
substantia nigra leading to Impairments often impact on activities of daily living
nigrostriatal dopamine
and how the person can participate in societal roles
deficiency sufficient to cause
in later life (Izaks and Westendorp 2003), and the ICF
classic motor manifestations
framework considers issues in context. For example,
followed by later non-motor
features due to extension of
environmental (physical and attitudinal) and personal
the pathology (medication, support) factors which can act as barriers or
facilitators in the analysis and subsequent planning of

Figure 24.1  Interactions between

Main Health Condition the components of the
(and subsidiary conditions)
International Classification of
Functioning (ICF). Permission to
reproduce granted by the World Health
Organization.

Impairments to body Activity limitations Participation

structures and functions restrictions

Environmental factors Personal factors

543
 Tidy’s physiotherapy
appropriate intervention. Consideration of the target level
(whether an impairment, activity or participation issue)
ensures that therapeutic management meets the current
status and needs of the individual. An appreciation of how
people live with ongoing (a set of) conditions using such
a bio-psychosocial and partnership approach to practice is
key to achieving person-centred management.
ASSESSMENT
Prior to physical assessment, consider the following:
• Consent and confidentiality. People within these
groups (older adults and people with Parkinson’s)
may fall into the category of ‘vulnerable adults’ and,
as circumstances alter over time, their needs and
support systems will change. Consent may have
to be elicited differently if, for example, speech
deteriorates in a person with Parkinson’s or if an
older person has a stroke and verbal communication
is no longer reliable. Sometimes tensions arise
between the individual’s rights and the professional or
organisation’s responsibility to that individual or the
Recommended reading
• The Mental Capacity Act (2005) with amendments to
both the Capacity and Mental Health Act (2009)
(http://webarchive.nationalarchives.gov.uk/+/
www.dh.gov.uk/en/SocialCare/
Deliveringadultsocialcare/).
• MentalCapacity/MentalCapacityAct2005/index.htm
puts the needs and wishes of a person who lacks
capacity at the centre of any decision-making process.
Particularly relevant to discharge planning if conflict
arises between the interdisciplinary team’s judgement
and the individual’s choice.
Clinical note
Active or inactive pathological processes will alter over
time, impacting on the individual’s lifestyle. An awareness
of pathological and normal physiological changes will
assist your assessments and help you decide on best
management.
It is easy to overlook how people are accepting and
adapting to the challenges they bring. Although our priority
is normally to deal with the physical disability, remember to
consider the possible psychological consequences; the
person can be referred to colleagues to ensure a holistic
approach to person-centred care is maintained.
544
well-being of the family. Examples include dealing
with confused individuals at risk of injury who insist
on returning home or a struggling carer whose
health is at risk yet refuses the help of strangers in
their house. As long as the person has capacity to
understand risks and take responsibility for them,
the choice is theirs.
• Ethics and law need considering, especially relating to
end-of-life decisions or when people have reduced
mental capacity requiring full discussion with family
and team (Dimond 2009).
• Confidentiality. Awareness of suspected elder abuse
or a more serious underlying medical problem is
important. Ensure that issues to be discussed outside
of the immediate ward/home environment receive the
person’s consent first and only then reveal information
relevant to the consultation (Whiddett et al. 2006).
• Recognising patterns of health and illness. The
relationship between age and disease lies along a
continuum making it difficult to distinguish between
them (Izaks and Westendorp 2003). For example,
postural changes, stiffness and restricted activity are
so often seen as a part of ageing that the rigidity and
bradykinesia of idiopathic Parkinson’s is missed.
Recommended viewing for Parkinson’s
Look up the following documents to help you formulate
in-depth ideas about the condition:
1. The Royal Dutch Society for Physical Therapy
Guidelines for Physical Therapy in Patients with
Parkinson’s Disease (Keus et al. 2004). It provides the
best available evidence for use in clinical practice and
can offer standardised guidance to physiotherapists
(https://www.kngfrichtlijnen.nl/downloads/Parkinsons_
disease.pdf).
2. The complete adapted version of the Dutch Quick
Reference Cards (Ramaswamy et al. 2009) (http://
www.parkinsons.org.uk/advice/publications/
professionals/quick_reference_cards.aspx).
3. Information from the Association of Physiotherapists
in Parkinson’s Disease Europe (APPDE) can be
accessed at: http://www.appde.eu/.
4. Information about cues and strategies to assist
movement can be found on the RESCUE site
(www.rescueproject.org). It is informed by multi-
centre research trials undertaken to look into the
impact of cues and physiotherapy.
5. A Professional’s Guide, published by the Parkinson’s
UK team in 2007, has a chapter dedicated to
physiotherapy assessment and intervention (http://
www.parkinsons.org.uk/advice/publications/
professionals.aspx).
 Physiotherapy management of Parkinson’s and of older people
Clinical note
AGILE is the clinical interest group of the Chartered
Society of Physiotherapy (CSP) and is comprised of
physiotherapists who work with older people.
The fundamental principles on which physiotherapy
with older people is based are:
• disability is generally regarded as being a result of a
pathological process or injury, not prima facie ‘old
age’;
• the effects of biological ageing reduce the efficiency of
the body’s systems but, throughout life, optimum
function is maintained in each individual by
Also be aware that people living with chronic illness
continually shift their perspective over time between one
of illness and one of wellness (Paterson 2001). Interven­
tion for these variations requires the skill of a different
professional (health or social) depending on the manifes­
tation of symptoms.
The assessments and principles of therapy should follow
suggested national protocols and guidance. Assessment of
older people differs from younger people only in the dif­
ferences in the body that occur with age; for people with
Parkinson’s, it is more the fact that symptoms may present
differently over the course of one day.
A comprehensive subjective and objective assessment
provides clarity of the clinical problem, ensuring the
information acquired enables the right decisions to be
made regarding the subsequent physical assessment.
Access to notes prior to assessment (electronic or hard
copy) will provide greater insight to the previous medical,
and current drug and social histories.
Clinical note
An informal consensus for AGILE (Ramaswamy and Jones
2005) provided four recommendations for physiotherapists
working with people with Parkinson’s. Physiotherapists
should:
• locate the aim of the episode of care as being either
(1) maintenance of the individual’s current movement
capability; (2) management of complex problems;
or (3) palliative care;
• ensure their baseline assessment comprises a
comprehensive set of data against which to monitor
change with disease stage;
• use appropriate outcome measurement to evaluate the
impact of a specific intervention;
• relate treatment strategies to problems identified at
assessment.
Chapter 24
continuing to use these systems to their maximum
capacity;
• physiotherapists have a key role in enabling older
people to use a number of the body’s systems fully to
enhance mobility and independence;
• when neither improvement nor even maintenance
of functional mobility is a reasonable goal,
physiotherapists can contribute to helping older people
to remain comfortable and pain-free;
• prevention of the development of problems in later life
is through health promotion (CSP 2005; AGILE 2008).
Recommended reading for issues regarding
older people
• Myths about ageing. There are many ‘myths of
ageing’. The WHO published a booklet for the
International Year of Older Persons in 1999 to shatter
these myths (http://whqlibdoc.who.int/hq/1999/
who_hsc_ahe_99.1.pdf).
• Demystifying the myths of ageing. Another WHO
booklet demonstrates how problems associated
with old age can be positively tackled (http://
www.euro.who.int/_data/assets/pdf_file/0006/98277/
E91885.pdf).
• Visit the AGILE website (www.agile.csp.org.uk) for
information about physiotherapy with older people,
and to download a copy of standards and principles
of assessment and intervention.
Bear these in mind when you consider the assessment
and management of Parkinson’s.
Assessment should be:
• undertaken at different points in the day (medication
cycle) if possible to capture variations in presentation.
This would reflect a ‘best’ and ‘worse’ episode,
highlighting functional difficulties experienced by the
individual;
• meaningful and functional, allowing identification and
monitoring of rehabilitation priorities;
• person-centred, focussing on perceived functional
difficulty and tailoring reassessment and intervention
accordingly.
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 Tidy’s physiotherapy

Box 24.1  Subjective assessment questions Table 24.6  Common conditions of older adults

Include: Category Examples

• history of presenting condition;
• past medical and surgical history; Orthopaedic Osteoporosis and osteomalacia,
• current medications, including over the counter conditions fractures – especially femoral and
medicines, e.g. herbal remedies; humeral necks, Colles’ and
• social history; vertebral fracture, Paget’s disease,
• what they perceive as the main issue(s); osteoarthritis and rheumatoid
arthritis
• what they know about their condition(s), i.e. do they
have literature about the condition; Neurological Cerebrovascular disease,
• previous experience of this issue and how they dealt conditions Parkinson’s, neuropathies and
with it; if new, what they perceive would be the best other such neurological conditions
outcome;
General medical Diabetes, falls, diverticulitis and
• impact on functional ability and lifestyle alterations;
conditions irritable bowel syndrome,
• expectations from physiotherapy. carcinomas, incontinence, urinary
tract infections, hernia – especially
hiatus, renal failure and thyroid
disorders
Subjective assessment
Cardiorespiratory Ischaemic heart disease,
Appropriate questioning allows the therapist to focus on conditions congestive cardiac failure,
the main presenting problem(s) (Box 24.1). Depending pneumonias, chronic obstructive
on their own experiences and those of people they know, pulmonary diseases
a person may make out they can do better or are worse
than you know them to be. For example, if a person is Psychological Depression (whether a stand-
falling a lot at home and during a hospital admission are conditions alone condition or secondary to a
afraid a decision they cannot cope at home will be made, disabling condition), dementia,
they may make out they could and are doing a lot for acute confusion, anxiety/fear of
falling
themselves at home. Work with colleagues (e.g. occupa­
tional therapists or nurses) to review if the information
has been corroborated by friends and family. Alternatively,
if someone has fallen and is afraid of returning home, they need a domiciliary physiotherapy referral to assess them
may seem reluctant to progress in therapy. Although chal­ at home.
lenging, analysis of such behaviour assists decision-making Depending on the reason for referral, the objective
for a supportive/empathetic or firm tactic, or both. assessment itself includes specific joint, nerve and muscle
Establishing agreed goals can be difficult where someone tests to assess the quality of these structures. It is especially
is unclear of their expectations from physiotherapy; insuf­ important to assess the person’s functional ability and
ficient understanding of their condition will limit expecta­ responses to tests of general flexibility, strength, power and
tions. A classic example on asking what the individual endurance. Balance, co-ordination and function are recog­
hopes to achieve by the end of their therapy is ‘I want to nised as the physical manifestations that affect independ­
walk better’. Your questioning should probe into how far ence (Guralnik et al. 2001).
they need to go indoors and out of doors, whether they Many older people make remarkable, and sometimes
need a mobility device or if they need assistance – only unexpected, recoveries from severe mental or physical
then can you agree realistic goals and set objective meas­ impairment. This process may be slower in the frail older
ures to gauge the outcome of your intervention. population and in those with Parkinson’s. With age
comes multiple-pathology, the most common conditions
of which are recorded in Table 24.6. An idea of the pa­­
Objective assessment thology of these conditions enables you to review what
This confirms the subjective history and the referral diag­ is ‘normal’, as well as what intervention you might
nosis, and identifies issues that require referral for further realistically offer.
investigation. Consider the assessment setting(s). For
example, if an older person attends an ‘osteoarthritis knee’
Drug history
class, they may improve in objective markers (joint range,
strength) used by the physiotherapist but this does Older people are often put on medication and left without
not indicate their coping ability at home; consider if they review until they reach toxic levels. Those with Parkinson’s

546
 Physiotherapy management of Parkinson’s and of older people
Recommended reading
Common ageing changes and thoughts as to how these
might influence a physiotherapist’s clinical decisions can
be found in the AGILE booklet or on the Physiopedia
site. Physiopedia is a resource aimed at international
collaboration, contribution and sharing of knowledge
and evidence for rehabilitation professionals throughout
the world using wiki technology. Access it at: http://
www.physio-pedia.com/index.php5?title=Main_Page and
look for the ‘Older People’ tab.
Also look at the ‘Physiotherapy’ chapter of the
Professional’s Guidance to Parkinson’s as it includes more
detailed information about the impact of
neuroanatomical changes in Parkinson’s.
progress to a combination of several tablets (polyphar­
macy), increasing the risk of drug interactions, adverse
reactions and non-compliance (Milton et al. 2008). Reac­
tions can be vague and non-specific, such as confusion,
constipation, hypotension and falls.
Medicines may be hard to swallow, but may be available
in a different form if necessary, including via a percutane­
ous endoscopic gastrostomy (PEG) for people in the late
stages of Parkinson’s. Also, if a bottle is hard to open or if
memory is a problem, different containers can aid dis­
pensing and concordance with medication.
Non-pharmacological management is becoming in­­
creasingly advocated. For example, a sense of loneliness
and low mood is natural following bereavement or diagno­
sis of a progressive condition such as Parkinson’s, and
a social network or counselling would help a person to
cope rather than sedatives and anti-depression medication.
An issue specific to Parkinson’s medication is the ‘on-
off’ phenomenon which dramatically affects the quality of
life for the individual. It refers to fluctuations in motor
function with the ability to move more freely in an ‘on’
phase when drugs are working well, to reduced ability to
function when drug action is reduced creating an ‘off state’.
Pain
Pain is a common issue for older people, as well as those
with Parkinson’s. Serious complaints, however, are fewer
than expected (Kumar and Allcock 2008) owing, in part,
to the fact that some older people mistakenly think that
pain is unavoidable so do not report it. In pathology that
causes intense pain in younger people (e.g. angina or frac­
tures), there may be so little discomfort or the pain may
present in such a way that diagnosis is delayed – some­
times with fatal consequences. Pain is often incorrectly
recognised and treated in people with dementia; in Par­
kinson’s, it may be present differently according to whether
Chapter 24
Clinical note
As Parkinson’s progresses, a combination of several
tablets is prescribed. In the older person, a dopamine-
replacement drug, for example Madopar or Sinemet,
is the main choice. Because of the increasing number
of side effects and impact on the motor system over
time with this category of drugs, i.e. dyskinesia or
‘on/off’ phenomenon, younger people diagnosed with
Parkinson’s are more likely to be prescribed a dopamine
agonist as first-line therapy, for example Ropinerole or
Rotigotine. There are also classes of drugs called
mono-amine oxidase inhibitor type B (MAOI-B), for
example Selegiline or Rasagiline, and catechol-o-
methyltransferase (COMT) inhibitors, for example
Entacapone or Tolcapone. While these work in different
ways, they basically make levodopa last longer or reduce
the amount required.
For more information about the drugs prescribed for
Parkinson’s visit http://www.parkinsons.org.uk/about_
parkinsons/treating_parkinsons/drugs.aspx.
it is as a result of injury or if it is manifested through a
non-motor symptom, for example sensory symptoms of
pain and paraesthesia (Mitra et al. 2008). In these cases,
it is better to work pragmatically, looking at the person’s
functional ability and management of pain instead of
looking at the restrictions it may cause.
Specific issues to assess in both the older population
and in those with Parkinson’s are the mobility-related
problems which increase over time. High percentages of
people over 50 years of age already self-report limitation
in physical function related to difficulty with mobility
and with basic activity of daily life (self-care) (DH 2004;
Banks et al. 2010). Nearly half of people with Parkinson’s
want to do activities outside of their home, such as social­
ising, visiting relatives or pursuing hobbies, but cannot;
common reasons why not were feeling too unwell, feeling
too tired, lack of public toilets, problems getting around
the streets, difficulties with transport and problems with
access to buildings (PDS 2008).
Recommended reading
• The English Longitudinal Study of Ageing (ELSA)
surveys people aged 50 and over about their lives in
England. Publications can be accessed at: http://
www.natcen.ac.uk/elsa/faq/about.htm.
• Assessment of mobility is important and a useful
website on motor control illustrating brain
connectivity is: http://thebrain.mcgill.ca/flash/d/
d_06/d_06_cr/d_06_cr_mou/d_06_cr_mou.html#2.
547
 Tidy’s physiotherapy
It is mainly through the basal ganglia and thalamic con­
nections that well-learnt, long and complex movement
sequences are controlled. The component nuclei and the
effect of the main neurotransmitter for the system,
dopamine, enable the co-ordination of the following
actions:
• pre-movement planning and preparation;
• initiation of movement;
• sequencing and timing of movement;
• maintaining cortically-selected movement amplitude,
i.e. the frontal cortex is involved in the choice of
movement, after which the basal ganglia takes over;
• habit-building;
• allowing the shifting of motor and cognitive sets
(Morris et al. 2010).
Clinical note
For Parkinson’s-specific assessments, see Quick Reference
Cards (QRC) (UK) 1 and 2 (Ramaswamy et al. 2009).
QRC1: History Taking and QRC2: Physical Assessment
suggest a baseline of evidence-based themes of
questioning and assessment.
Transfers
This refers to movement from one stationary point to
another, such as rising from a chair or bed, getting in and
out of a car, or up off the floor. With age, the lower spine
becomes less flexible; the combination of limited joint
range with slowed movement sequences affects momen­
tum so, on standing, the person’s centre of gravity is too
far back in relation to their feet and they fall backwards
(Morris 2000).
People with Parkinson’s mention bed mobility and
transfers as difficult tasks, especially turning to get com­
fortable, or getting into and out of bed. This occurs with
a progressive decrease in spinal rotation from bradyki­
nesia. Rigidity, the loss of automatic movement and a fear
of rolling off the bed is worse if the person has dementia
or is easily confused. As Parkinson’s progresses, transfers
involving a turn become more problematic. To turn 180
degrees, the feet must have good ground clearance; stabil­
ity is needed through the legs to the trunk, plus continuity
of movement and good posture assist in transition of
weight in the upright posture. A fit, older person may be
Clinical note
Because of the high risk of falls, both older people and
those with Parkinson’s need to be assessed for their
ability to rise from the floor (Keus et al. 2004).
548
able to turn 180 degrees in two to three steps, while an
older person without Parkinson’s may do it in five steps
or fewer (Simpson et al. 2002). Someone with progressing
Parkinson’s will take over four steps and will tend to
favour turning in one direction over another; some people
may freeze when simply thinking about turning (Stack
et al. 2006). Transfers and bed mobility can be assessed as
part of the Lindop Parkinson’s Assessment Scale (LPAS)
(Pearson et al. 2009), and in the Modified Parkinson’s
Assessment Scale (MPAS) (Keus et al. 2009).
Posture (including range of  
joint movement)
Posture becomes increasingly flexed – especially in people
with Parkinson’s (described earlier) who might develop an
unstable posture that brings them up onto their forefoot,
affecting all aspects of mobility in the later stages of the
condition. In both populations, stiff trunk muscles reduce
the range of movement, limiting trunk rotation and mus­
cular extensor activity (Laughton et al. 2003). In Parkin­
son’s, leg muscle strength, particularly of the knee and hip
extensors has been proven to be weaker than healthy
controls (Inkster et al. 2003). Trunk stiffness affects the
counter-rotational ability of the thorax on the pelvis until
they rotate in the same direction. Again, this is generally
worse in people with Parkinson’s unless the older person
has a spinal condition, such as osteoporosis or ankylosing
spondylitis. The onset of flexion is often insidious, leaving
people unaware it is occurring until you take a photograph
and show a ‘normal’ versus ‘good’ posture.
Clinical note
Use your assessment to distinguish whether the postural
imbalance is permanent, through a fixed shortening, or
whether subsequent intervention may be able to correct
or improve it. Also, review the seating position, as people
may sit for prolonged periods leaning to one side, or in a
very slumped position.
Balance
Balance is of concern to both the older and the Parkinson’s
populations as it is a major contributor to falls. In Parkin­
son’s, a person’s ability to balance is typically affected in
Hoehn and Yahr stage III and people will report increasing
difficulty in dual or multi-tasking. This affects many
aspects of daily life, such as walking and talking, or walking
while carrying bags (Rochester 2004). The effect of muscle
disuse and stiffness (rigidity in Parkinson’s and brady­
kinesia), functional range of movement, strength and
 Physiotherapy management of Parkinson’s and of older people Chapter 24

Table 24.7  Common gait changes in older people and in people with Parkinson’s

Changes Comments

Slower pace From decreases in hip amplitude and speed of movement. Average speed of 0.75 m/s can
decrease to below 0.4 m/s – less if a person with Parkinson’s freezes

Reduced step and stride Asymmetry of Parkinson’s will affect one leg more than another or a condition such as stroke,
length arthritis or orthopaedic surgery

Increased double stance This phase is increased from 11% to 25% of the gait cycle
time

Increased flexion in Affects hip extensors and calf muscle recruitment; worsens once a person begins using a
posture mobility device

Reduced arm swing and Affects momentum and counterbalance action. More noticeable in people with Parkinson’s.
body movement Also affected when a person begins using a mobility device

Decreased foot clearance Toe clearance during the swing phase decreases as a result of reduced active hip flexion and
calf work. Can result in tripping

Shuffle in later stages May be Parkinson’s but may be higher level gait disorder from another vascular cause.
and festination A ‘festinating gait’ describes the short, quickening gait pattern, when the person with
Parkinson’s is flexed forward and on their forefoot, pulling the centre of gravity out of the
base of support so they lose control of forward motion and often fall forward

Freezing or initiation Assess whether initiation problems (where the person cannot set off), freezing (which occurs
problems during the course of an activity, resulting in the person coming to a standstill mid-movement)
or termination difficulties (where the person is unable to moderate their reactions to stop
while walking) are experienced

posture make it very difficult for muscles to react as quickly

Table 24.8  Gait disturbances in advanced
as normal to rapid changes in body position. This provides Parkinson’s
a cause of postural instability which, in turn, impairs right­
ing and equilibrium reactions, increasing the likelihood
Parkinson’s features Gait disturbances
of falling (see later section).
Hypo-/bradykinesia Shorter steps, slower, less
Functional gait (including freezing, arm swing, festination

and indoor and outdoor mobility) Rigidity (with abnormal Joint motion, flexed
posture) posture
Walking is slowed as people become older and in
those with Parkinson’s. Some aspects, such as freezing Disturbed postural response Fear of falling, hesitated
during gait or festination are particular to Parkinson’s, gait, festination
while other features, for example small steps, are common
Disturbed automatic motor Start hesitation, freezing
to all (Table 24.7). tasks of gait
There are a number of different ways of describing the
Parkinson’s gait. The stooped posture with hip and knee Disturbed autonomic Weakness, light-headed
flexion, small shuffling steps, lack of trunk rotation, function unsteadiness
heel strike and reduced arm swing is well documented
Involuntary movements Dystonia or dyskinesias
(Knuttson 1972; Murray et al. 1978), but, at times, could
just as easily describe the gait of an older person with
severe arthritis or post-stroke. Distinguish the components appear glued to the floor. It is a major cause of falls
of movement that are causing the decreased efficiency of and one of the most disabling symptoms of Parkinson’s,
gait (Table 24.8). with the incidence reported to be greater than 50% in
Freezing of gait (FoG) is a form of akinesia (loss of people who have had Parkinson’s for more than five
movement) known as ‘motor block’, a ‘sudden transient years (Giladi 2001). It predominantly affects the limbs
inability to move’ (Jankovic 2008), whereby the feet while walking, but has also been identified in the upper

549
 Tidy’s physiotherapy
limbs and during speech. There are five subtypes of
freezing: hesitation at start, turn, in tight quarters, at des­
tination and open space.
It is known that frequency and duration of FoG increases
with disease severity and duration, but as it occurs at all
stages of Parkinson’s, it should be assessed accordingly.
Identification of FoG can lead to the timely implementa­
tion of appropriate treatment and management with
the aim to optimise function for those with freezing
difficulty.
Gait initiation is a major cause of falls with significant
differences in gait initiation between young and elderly
populations, normal elders and those with Parkinson’s. A
research study investigating this comparison of normal
elders with those with Parkinson’s and gait initiation dif­
ficulties when utilising different cueing devices is currently
underway (McCandless et al. 2011).
General mobility
Teaching mobility may sometimes mean testing safety
with a wheelchair, including transfers.
Falls
A fall is defined as: ‘An unexpected event in which the
participant comes to rest on the ground, floor or lower
level’ (Lamb et al. 2005).
Key point
Falls and bone health are a major cause of disability in
both populations, with a high risk of accidental home
deaths resulting from injury. Many interventions provided
through physiotherapy, or physiotherapy as part of a
team, have been proven to modify the risk and help to
prevent future falls.
At least 35% of those over the age of 65 years fall every
year, with records as high as 50–60% in the Parkinson’s
population (Bloem 2001; DH 2009). The annual inci­
dence of falls in individuals recorded with dementia was
40–60% in 1998 (Shaw and Kenny 1998).
The costs of a fall include health and social service costs,
for example from treatment of injury or formal care during
recovery. Perhaps the most important cost is the psycho­
logical toll it takes on the person, especially if they are
prone to falling (DH 2009).
In frail older people and those with later stage Parkin­
son’s, a fall can result in hip fracture, a requirement to
accept long-term nursing care or even death.
The cause of falls is multi-factorial, for example ageing,
pathology, inactivity and environmental factors, with
over 200 risk factors identified (Lord et al. 2007), and, as
550
Box 24.2  Recommended areas for identification
and assessment as the leading causes of falls
• Alteration to gait, balance and mobility, or muscle
weakness.
• Older person’s perception of functional ability and
fear relating to falling.
• Visual impairment.
• Cognitive impairment.
• Alterations on a neurological examination.
• Urinary incontinence.
• Presence of home hazards.
• Cardiovascular pathology.
• Medications prescribed.
such, the assessment process should also be multi-factorial
(Box 24.2).
Cognitive impairment is an independent risk factor for
falls. Nevertheless, older persons with cognitive impair­
ment have been excluded from most of the successful
falls-prevention randomised controlled trials in the com­
munity setting. Wraith and Criddle (2008) demonstrated
both a reduction in falls in people with dementia in a
carer-directed home exercise programme and also that
these programmes maintained quality of life for people
with dementia over 12 months.
Clinical note
Physiotherapists can assess falls factors using the DAME
mnemonic:
D – drugs and alcohol
A – age-related physiological changes
M – medical (includes psychological, as well as physical
factors)
E – environmental
Not all falls can be explained. Falls may be intrinsic in
nature, for example postural hypotension, visual defects
and a person’s cognitive state, or extrinsic in nature, for
example medication, footwear or the environment. Falls
amongst people younger than 75 years are more likely to
be a result of extrinsic factors than those aged 75 and over.
Posing a question correctly will determine the content
and accuracy of response. For falls and near misses (an
indicator of falls risk), the following wording is recom­
mended: ‘In the past month, have you had any fall, includ­
ing a slip or trip in which you lost your balance and landed
on the floor or ground or lower level?’ (Lamb et al. 2005).
Functional ability may be assessed subjectively, for
example question how a person manages personal and
 Physiotherapy management of Parkinson’s and of older people
domestic activities of daily living, and also observe how
the person stands up from a chair; assess the person’s
ability to multi-task, for example walk and carry objects,
walk and talk (as poor walking responses in a dual-task
setting are a possible prognostic value for multiple falls)
(Faulkener et al. 2007).
For people who have fallen, when assessing specific
injuries that might have been sustained during a fall,
consider AGILE’s four identified aims (Goodwin and
Briggs 2012):
1. To prevent falls;
2. To improve the older person’s ability to withstand
threats to their balance;
3. To prevent the consequences of a long lie;
4. To optimise confidence and reduce fear of falling.
In Parkinson’s, falling when a person is walking is most
common in a forward direction (Bloem et al. 2004)
although people commonly fall backwards or take several
attempts to generate sufficient forward momentum
when getting up from a chair or the bed. A large pro­
portion of falls also happen when a person with Par­
kinson’s is turning, owing to a combination of effects,
including slow response to the eye-head co-ordination,
weight-transfer and freezing. Specific evidence relating to
falls and physical capacity is still very limited and warrants
further research (Rochester 2010). It is noteworthy that if
mobility improves with balance, gait training and cueing,
fall risk can increase owing to new found mobility and
increased fall risks.
Recommended reading
Read the NICE Guideline on Assessment and Prevention
of Falls in Older People CG21 (2004) (http://
guidance.nice.org.uk/CG21) and the Parkinson’s UK
information section Falls and Parkinson’s (http://
www.parkinsons.org.uk/advice/publications/motor_and_
non-motor_symptoms/falls_and_parkinsons.aspx).
Mental health
A decline in mental health can hinder and limit a person’s
participation and progression with physiotherapy. Physi­
otherapy for mental health problems varies depending on
the reason for the condition and the stage it is at; however,
there are recommended good practice points for us to
follow (Box 24.3). Some physiotherapists specialise in this
clinical field post-qualification.
When engaging with people with dementia in mobility-
related activities Oddy (2004) states that consideration
should be given to providing frequent reminders; utilising
clear and short instructions; using familiar words or cues;
knowing a person’s likes and dislikes; offering reassurance;
Chapter 24
Box 24.3  Good practice points when working
with people with mental health problems
The physical treatment may involve:
• a thorough assessment of ability, with involvement
from other MDT members;
• maintenance of range of movement (especially in the
later stages when immobility increases) and work on
promoting mobility;
• improvement of balance, to minimise the risks of
falling, as mobility declines;
• treatment of any specific injuries sustained;
• provision of information to help reduce anxieties and
fears, and assistance in carrying out a specific
programme designed for that individual;
• teaching of positioning and manual handling in the
later stages of some of the disorders.
checking medication for hypotension and medication
side effects that may affect balance; and checking foot­
wear is safe.
Dealing with someone who is anxious or confused will
develop skills in empathy and in patience, as well as your
basic listening and counselling skills. This may also be
either with the individual or a stressed family member,
giving insight and an understanding of their environment
and behaviour.
INTERVENTION
Physiotherapy assessment and treatment focusses prima­
rily on physical issues. In these two populations, in addi­
tion to reviewing overall function, do not ignore specific
manual techniques, as the mechanical changes to posture
and joints will require appropriate mobilisation and
exercise.
The difference in approach is often during clinical rea­
soning where you have to piece together implications of
multiple pathology and complexity of the social context
in addition to physical presentation.
Goals
As with any individual, the goals agreed should be
directed towards management and, if appropriate, condi­
tion improvement. Your assessment of pre-referral ability
compared with current ability will help identify the per­
son’s rehabilitation potential. You will need to consider
which presenting feature relates to de-skilling, decondi­
tioning, pathology or ageing, and, therefore, which are
reversible and manageable. All the while, consider the
551
 Tidy’s physiotherapy
realism of the person’s expectations, their safety and the
support they might get.
If in a hospital or community team setting, decision-
making occurs with consultation of the individual, their
family and health and social service teams. When plan­
ning discharges, or after a home visit, goals may have to
be reviewed.
Clinical note
Good practice issues to consider when agreeing goals
and planning for discharge are:
• that you understand the meaning of the illness to the
person or relative so you can agree on appropriate
interventions and goals. You can put it in context, i.e.
how important is the illness and its treatment compared
with other social/psychological/physical problems?;
• that you are aware of the individual’s style of coping
with illness/disability, e.g. avoidance, emotion-
focussed, problem-solving;
• knowing their mood and cognitive status (depression,
anxiety, confusion), as it will affect learning,
participation and carry over;
• knowing if there are hidden implications to that
person in terms of difficulty in performing exercises
you have asked of them and their energy
requirement, the time it takes, if there is pain or
discomfort, if there are actual or perceived risks, and
visibility of progress for motivation. Are there any
financial implications? The person may feel that these
far outweigh any benefits of exercise.
Measuring outcome
Outcome measurement is both a requirement of compe­
tent physiotherapy practice (CSP 2005) and a government
requirement (DH 2010). It can be difficult to distil the
physiotherapy-specific input in populations requiring
team involvement as the outcome is dependent on input
from the whole team. For example, the physiotherapist
and occupational therapist will measure different aspects
in the person’s function and the nurse may measure
overall change to life quality. What gets measured (usually
pre-to-post intervention, episode or unit of care) depends
on your definition of ‘the outcome of interest’, on who
wants the data and for what purpose. For example, a
service manager or commissioner will want a measure of
the cost to deliver a service as opposed to a therapist
measuring change following intervention.
If an assessment form is used as a measuring tool, for
example the Elderly Mobility Scale (Smith 1994), still
assess the specific impairments underlying the individual’s
needs and also choose the correct measuring tool to
552
measure the outcome of intervention. There are many
measures you can choose depending on factors such as
pathology or function. Table 24.9 lists the most com­
monly used tools; full details and references for these can
be looked up on any good database, including the CSP
outcome measure website, or in a book specifically dealing
with outcome measurement.
Although tools are usually chosen on their properties
of validity, sensitivity and specificity to the person’s need,
not all situations have such measures.
Specific intervention for people
with Parkinson’s
Physiotherapy has now been proven of benefit to people
with Parkinson’s (Tomlinson et al. 2012). In the earlier
stages of Parkinson’s, physiotherapy may only incorpo­
rate education and advice to enable maintenance of
fitness levels and to minimise progression. The physio­
therapist may also be involved at this stage in prescribing
specific exercises to the individual so they can regain
movement, prevent falls, maximise respiratory function
or reduce pain.
As the condition progresses, intervention moves from
maintenance to promotion of independence by using a
wider network of support, whether asking family to assist,
or requesting formal social services intervention. Finally,
in the palliative stages, input becomes necessary to relieve
pain and pressure areas, treating symptoms as they occur
(Keus et al. 2004; Ramaswamy and Jones 2005).
General intervention in the form  
of physical activity and exercise
Definition
Physical activity is considered to be ‘any bodily movement
produced by skeletal muscles that results in energy
expenditure’, while exercise is defined as: ‘Leisure time
physical activity which is planned and structured, and
repetitive bodily movement undertaken to improve or
maintain one or more components of physical fitness’
(Caspersen et al. 1985).
Physical activity is an umbrella term for many activities,
including exercise, sport, dancing, gardening and walking.
Regular physical activity is essential for physical and
mental well-being across all age groups and conditions.
There are very few physical and mental conditions that
regular exercise does not help to prevent, or reduce the risk
of developing or improving symptoms.
 Physiotherapy management of Parkinson’s and of older people Chapter 24

Table 24.9  Commonly used outcome measures

Purpose Common Parkinson’s examples Common older people

examples

Global measures Barthel scale; the functional independence measure (FIM) or the therapy outcome
measures (TOMs) done by the multi-/ interdisciplinary team

Stage or age specific measures Hoehn and Yahr disease staging Elderly Mobility Scale

Disease or condition specific Unified Parkinson’s Disease Rating Scale (old and Scales for Parkinson’s disease,
scales new versions); arthritis, stroke, pain,
Parkinson’s Activity Scale (disease-specific) cognitive state, etc.

Function specific tools – may
look at particular aspects of
function, e.g. balance,
turning, gait, etc.
Rivermead Index; timed get up and go; multiple Timed get up and go test;
tasks test – postural control Tinetti evaluation
Turning with: standing start 180 degree turn test; (performance oriented
turning in bed; turning step count (on spot and assessment measure) of
during turning) balance and gait
Balance: Berg balance scale; functional reach (FR) Turning: 180 degree turn test
Postural stability: retropulsion test Balance: Berg balance scale, FR
Gait: 10-metre walk; freezing of gait Gait: 10-metre walk; 6-minute
(First) step length walk

Patient-specific measures or Treatment evaluation by the Le Roux method TELER and GAS
patient reported outcome (TELER); Goal attainment scoring (GAS)
measure (PROM) Utility of cueing devices for Parkinson’s
(McCandless et al. 2010)

Emotional status Carer Strain Index

Quality of life scales PDQ-39, SF 36 SF 36, WHO – quality of life

for older people

Self-assessment scales EQ5D (perceived health state); Falls Efficacy Scale

It is known that physical activity is reduced in the older

population and in those with long-term conditions whose
lives become more sedentary (Guralnik et al. 2001; Banks
et al. 2010). Preferred exercise or sport should be contin­
ued as long as possible alongside education on the ben­
efits of exercise. Older adults engaged in regular physical
activity demonstrate improved balance, strength, coordi­
nation and motor control, flexibility and endurance.
Newer technology, for example the Nintendo-Wii, can
improve well-being in older adults, at home and in resi­
dential care, and are useful for socialising and inter-
generational fun.
Reduced physical activity levels can occur as a result of:
• falls and injury – if the person has Parkinson’s, this
might be from bradykinetic-rigid syndromes or
freezing (Bloem et al. 2004);
• increasing rate of disease complications and
disability (comorbidity) in addition to motor
impairment alone, in more advanced disease stage or
with age (strength and function);
• cardiopulmonary decline and the resultant secondary
complications.
Key point
As physiotherapists, we can influence people of all ages
to increase their physical activity levels and educate them
to improve their general state of health and well-being.
As with the older population, the fields of cellular
biology and animal-model research are increasing evi­
dence of exercise benefits at central nervous system level
showing increased learning, and neuroplastic increases in
dendritic spine density and synapse number. The impor­
tance for people with Parkinson’s is the additional possi­
bility that this may serve as a neuroprotective function,
minimising progression of the course of the condition
(Fisher et al. 2008; Petzinger 2010); this emerging evi­
dence is starting to influence clinical practice.
Physiotherapists should set a progressive exercise
regime, ideally to be completed regularly in the home
environment. The use of a structured exercise programme
in picture booklet format for illustration and guidance
can be particularly helpful (Pang et al. 2006).

553
 Tidy’s physiotherapy
For people with Parkinson’s, components in the exercise
programme should include:
• exercising – large amplitude movements (amplitude
training) emphasising rotation and extension in
sitting, and lying and standing for trunk and limbs;
• facial, speech and breathing exercises should also be
included;
• targeted training for gait, transfers, balance, resistance
and flexibility exercises;
• postural awareness (relaxation).
Exercise or targeted training should be undertaken at the
peak dose of the medication cycle (Keus et al. 2004).
Important considerations specific to the older adult popu­
lation include:
• that the intensity of aerobic activity takes into
account the older adult’s aerobic fitness;
• activities that maintain or increase flexibility;
• balance exercises for older adults at risk of falls;
• that older adults that have medical conditions or
disabilities that may affect their capacity to be
physically active should seek advice from a doctor.
Examples of exercise include treadmill training leading
to an improvement in gait and balance, and mood and
cognitive function. Treadmill training can improve gait
parameters (Fisher et al. 2008), lower limb tasks and
increase muscle size (hypertrophy).
There are functional and behavioural benefits in
response to different forms of exercise and part of a physi­
otherapist’s role is to identify any barriers and enablers to
gait initiation, physical activity and exercise. Recom­
mended exercise includes Tai Chi, boxing, Nintendo Wii
Fit and tango dancing. For people with Parkinson’s, Argen­
tine tango dancing utilises music as the auditory cue and
corresponding dance steps as the movement strategy
which, if done for one hour, improves both gait and
balance.
More detailed guidance for exercise testing (aerobic,
endurance, strength, flexibility, neuromuscular and func­
tional) and exercise programming (aerobic, endurance,
strength, flexibility, functional) is given by the American
College of Sports Medicine (ACSM 2009). It is important
to note the variability of symptoms and response to
exercise owing to autonomic dysfunction, such as altered
heart rate, blood pressure and response to heat, alongside
effects of muscular rigidity raising heart rate and oxygen
consumption.
Recommended reading
Look at information (with video links) to the SPRING
conference of 2009 about evidence for the positive effect
of exercise on Parkinson’s symptoms (http://spring.
parkinsons.org.uk/images/stories/ExerConf/
ExConfBooklet.pdf).
554
Physical activity and exercise  
for falls
Of all the above interventions, for physiotherapists, exer­
cise (for strength and balance) has been shown to have
the most effective outcomes in falls-management, with a
reduction in falls rates, including high falls-risk inpatients
on subacute wards (Sherrington et al. 2008). As the major­
ity of people who attend such programmes relapse into
old ways by six months, the physiotherapist should
attempt to reinforce and encourage a change in behaviour,
eliciting ideas of what might keep the person motivated
both during the course of the programme and into
the future, in addition to the physical perspective. This
is becoming the focus of health promotion and multi-
disciplinary intervention has been proven to be of most
effect for fallers (NICE 2004).
The research by Sherrington et al. (2008) demonstrates
that clinicians have to ensure that:
• the balance training is highly challenging,
individualised and progressive;
• exercise should be done at least twice a week and for
a minimum duration of six months;
• walking should only be prescribed in addition to a
high intensity/high dose programme.
Balance impairment and falls are a frequent disabling
consequence of Parkinson’s (Morris et al. 2010). Freezing
and falls significantly impact their everyday lives, with an
increased risk of comorbidities and admission to nursing
homes. As freezing may be a predictor of falls, the inclu­
sion of freezing in falls assessment is needed, for example
the New Freezing of Gait Questionnaire (N-FOGQ).
Freezing of gait (FoG) is one of the key problems for
the Postural Instability and Gait Disorder (PIGD) group.
Cognitive and motor-loading during dual tasking, for
example walking and talking, increases the odds of FoG
episodes and falling.
Principles of physiotherapy practice
and Parkinson’s (Morris et al. 2010)
Evidence-based research and guidelines can be distilled
into a wide range of contemporary physiotherapy-based
treatments; however, they can be usefully categorised as
follows:
• motor skill learning in skill acquisition;
• teaching people strategies to enable them to move
more easily;
• treatment of secondary problems, such as cardiac
de-conditioning and muscle weakness;
• educational and health promotion to reduce the risk
of falls, increase physical activity levels and, thus,
influence social participation.
The above treatment and management strategies are tar­
geted at addressing every level of the ICF: impairment,
 Physiotherapy management of Parkinson’s and of older people
activity limitation and participation, and interventions
must be tailored to ensure individual’s needs are met.
It is useful, as part of the assessment, to categorise
patients into early-, mid- and late-stage Parkinson’s in
order to tailor the treatment approach accordingly. Exer­
cise, cueing and movement strategies are three key areas
of intervention for people with Parkinson’s. These can be
combined for best effect.
• Early-stage: motor skill learning.
• Mid-stage: resistance training; compensatory.
• Late-stage: secondary sequalae; dance.
In addition to the ‘prescribing’ of exercise for people
with Parkinson’s, the other area of evidence for the effec­
tiveness of physiotherapy is in maintaining and accessing
automatic movement patterns through the choice of
appropriate cues and cueing strategies (Lim et al. 2005;
Rochester 2005; Nieuwboer et al 2007). Cueing can be
effective in the short term within the home environment;
however, longer-term effects are yet unknown (Nieuwboer
et al. 2007). Similarly, the laser-cane (a walking stick with
a laser light as a visual cue) was proved to be an effective
cueing device at overcoming freezing during gait initiation
compared with auditory cues and vibratory cues in the
laboratory, but its effectiveness in the home and outdoors
(short- or long-term) has yet to be evaluated (McCandless
et al. 2010).
Table 24.10  Commonly used cues
Cues Examples
Visual Strips of card on the floor can assist
step length and initiation
problems
Strategically placed cue cards with
a keyword to activate movement
Laser cane
Laser-walker
Auditory Metronomes, a musical beat or
voice can help gait initiation and
maintenance
Proprioceptive Rocking side-to-side taking a step
backwards can help overcome
freezing; trial with functional
electrical stimulation (FES)
Internal cueing Memorising separate parts of the
self-instruction movement and rehearsing them
Cognitive mentally
Taking a big step; walking fast;
counting aloud while walking;
visualisation of parts of a
movement sequence; visualisation
of a set step length and adjusting
walking to step with that size
Chapter 24
Table 24.10 provides some of the common types of cues
recommended and the evidence base for these.
To help process some of the information from this
chapter, we have provided a case study to highlight the
goals, aims and examples of treatment plans based on
guidance for physiotherapists working with Parkinson’s.
Read through the case study and guidelines while consid­
ering the following:
• ICF (impairment, activity, participation);
• stage of the condition (anatomical location of
progressive pathology: lower brainstem, middle
brainstem or cortical involvement = dementia);
• person-centred goals;
• principles of management at early-, mid- and
late-stage;
• the role of physiotherapy – assessment, treatment,
‘coach’, advisor, exercise prescriber;
• relevant outcome measures.
Consider QRC 2 in particular and which key elements
of assessment you would include if the person in the case
study was not early diagnosis, but older and at mid- or
late-stage. Finally, go one step further and consider how
your assessment and input would differ if it were an older
person with dementia (cortical involvement).
CASE STUDY: EARLY STAGE NEW
DIAGNOSIS – HOEHN AND YAHR 1
Katherine is 40 years old, is married with two pre-
teenage children and works full-time as a secretary for a
large department store. She has just been diagnosed
with Parkinson’s. She is anxious her employer remains
unaware and is keen to work as long as possible. She
presents with mild right (dominant) hand and complains
of backache after sitting at her desk. Her voice has
become quieter making telephone conversations
problematic on occasion. Katherine enjoys spending time
with the children and drives them to athletics and
after-school swimming club. She has noticed both her
legs feeling stiffer than normal and has stopped
attending ballroom dancing with her husband. Katherine
occasionally loses her balance (trips and overbalances
forward) while walking her golden retriever on uneven
ground. She would like to try playing golf but lacks
confidence.
GOAL: MANAGEMENT/TREATMENT
(TABLE 24.11)
1. Increase aerobic capacity in and outside the work
environment.
2. Retain current employment and independence as long
as possible.
3. Take regular meaningful activity/exercise/sport
individually and with the whole family at least once a
week.
555
 Tidy’s physiotherapy
Table 24.11  Recommended treatment goals and strategies to manage Parkinson’s
Stimulation Goal (for early phase) QRC 3
of activities
Transfers Prevention of inactivity
Motor skill acquisition
Body posture Increase postural awareness and
reduce back pain at work
Reaching and Maintain hand dexterity, reaching/
grasping grasping
Balance Identify balance problems (linked to
fear of falling while dog-walking)
Gait Improve gait speed using Nordic
walking poles.
Simple cardiac monitor
Prevention 75–80% target heart rate 5–8 mph
Average energy expenditure 4.3
metabolic equivalents (METS)
(Fisher et al. 2008)
Inactivity Preserve or improve physical condition
Prevent cardiac deconditioning
See American College of Sports
Medicine (ACSM) Guidelines 2009
For exercise prescription in Parkinson’s
disease
Research local golf facilities and
charitable organisations
Falls Prevent fear of falling while out
dog-walking on hills/uneven
ground
CONCLUSION
As mentioned at the start of the chapter, Parkinson’s can
be very different clinically to the management of older
adults. As with any population, a physiotherapist learns to
explore clinical problems through subjective and objective
assessment, adhering to a patient-centred approach with
‘shared decision making’ (DH 2010) and implementation
556
Strategy QRC 4
Warm-up and stretch prior to tango dancing with
husband
Postural exercises at work for endurance and flexibility in
spinal extensors (neck and back); limit time in flexed
sitting position.
Ergonomic assessment at work
Lumbar roll at work and while driving
Practise throwing/catching balls while walking the dog
or playing Frisbee with the children
Training for 5 km school charity ‘fun run’ will increase
strength in lower limbs (important for prevention of
falls)
‘Fast walking’ (power walking)/Nordic walking with
group at lunchtime twice a week
Use of intense exercise to act as neuroprotective agent
Minimum 30 min exercise 5 times a week
Train for 5 km fun run while children at athletics after
school – aerobic exercise
Use heart rate monitor, warm-up cool-down, include
stretches for hamstrings and gastrocnemius
Provide information on keeping active through sports
swimming once a week with family, ballroom dancing
(with husband for one hour a week)
Find a ‘golf buddy’ to accompany Katherine, consider
organising a golf group for people with Parkinson’s
once a week. Match medication timing to tee-off
schedule
Walk the dog on an area where the dog can run freely
(without a lead), thus reducing risk of being pulled
forward/off-balance by the dog on the lead
Strengthen lower limb muscles using a gym membership
or home exercise programme
of best practice utilising evidence-based guidelines, such
as those for Parkinson’s (Keus et al. 2004).
In general terms, it is useful to consider aspects of both
Parkinson’s and of older adult conditions as being similar
to an iceberg; the ice above the water comprises the physi­
cal alterations we are referred to assess in these popula­
tions, whereas the larger expanse of ice below the water
comprises non-motor problems. These latter problems are
often hidden or unrecognised, yet an understanding of the
 Physiotherapy management of Parkinson’s and of older people Chapter 24

impact of such symptoms for the individual, relatives and

Recommended reading
Carry out a literature search for authors such as Diana
Jones, Meg Morris, Alice Nieuwboer, Lynn Rochester and
Nir Giladi. They have written extensively on physiotherapy-
relevant articles reviewing the mechanisms of gait in
people with Parkinson’s, mainly describing people with
bradykinetic-rigid symptoms or those with freezing.
Few articles research dyskinesia, where the gait pattern
can be so erratic that assessment is difficult, and the
treatment plan follows alleviation of current symptoms.
carers is vital. They are a key to facilitating identification
of person-centred goals as targets for treatment.
The guidance on assessment in the chapter should help
you highlight the person’s clinical need. The toolkit of
interventions provided will enable the achievement of
agreed goals, and the information on physical activity
linked with accurate measurement of progress utilising
appropriate outcomes will help you to promote a good
holistic intervention.
We hope you will also use the recommended reading
and websites to read more around the issues and to
develop a broader understanding of these subjects.

ACKNOWLEDGEMENTS

A big thank you to all the therapists, patients and people we know who agreed to be photographed for this publication,
and from whom we are still learning. Bhanu would like to thank all of her AGILE colleagues: Sal Foulkes, Vicki Goodwin,
Diana Jones, Fiona Lindop, Penelope Reynolds, Amy Sheppard and Lynn Whyke for ideas, opinions, ears and patience
during this undertaking. To members of the Parkinson’s UK (Sheffield Branch) Classes and Committee for unfailing
support, and finally to my family, especially my father, who set the bar for my high practice standards, and my physi­
otherapist husband Michael Heys for mobilising my back and neck when I could tear him away from the rugby league
and football. Paula would like to thank UCLAN student physiotherapist Ryan Pope, a student research intern and CSP
representative who presented a Parkinson’s UK-funded project on the effectiveness of cueing devices in Montana 2010.
Finally, thanks to UCLAN International physio­therapy student Shiva Mauree, a physiotherapy research intern who pro­
vided photos for this edition.

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 Chapter
Neurodynamics
Monika Lohkamp, Lee Herrington and Katie Small
INTRODUCTION
In 1864, Lasegue first described the straight leg raise test
(SLR) as an assessment for lower back problems with
nerve involvement (Butler 1991). This concept was further
developed by Goddard and Reid in 1965 who described
the SLR as movement of the sciatic nerve. Also, in the
1960s Alf Breig investigated the biomechanics of the
nervous system in more detail and showed that nerves
move independently from other tissues. This formed the
basis of the concept of ‘neurodynamics’. Earlier terms for
this concept were ‘neural tension’ (Breig 1978) or ‘adverse
mechanical tension of the nervous system’ (Butler 1989).
However, the actual term ‘neurodynamics’ was first intro-
duced by Gifford in 1989. The concept of neurodynamics
has been further developed by Grieve, Butler, Maitland
and Shacklock over the last 30 years. Nowadays, although
neurodynamics remains a relatively new concept within
musculoskeletal clinical assessments, it is becoming more
widely used and accepted as an important aspect for injury
assessment and treatment.
Mechanics of the peripheral   and intrafasicular capillaries stop flowing. This occurs at
nervous system
In general terms, the nervous system can be divided into
the central nervous system (CNS; brain and spinal cord),
peripheral nervous system (all nerves after leaving the
nerve roots within the spinal vertebrae) and autonomic
nervous system (sympathetic and parasympathetic divi-
sion) (Michael-Titus et al. 2007). The central and peri­
pheral nervous system are closely connected through
meninges (Butler 1991). The mechanical and physiologi-
cal properties of peripheral nerves are crucial in their
ability to function well.
The peripheral nerves are not only involved in conduct-
ing impulses and chemical traffic, but are also considered
as dynamic tissue in the same way as muscles and joints.
25 
Along with the CNS, the peripheral nerves are designed to
function while stretching and sliding (longitudinal and
transverse motion) as a result of a wide variety and range
of body movements (Shacklock 1995). When nerves are
sliding they always slide towards the joint where move-
ment takes place (Coppieters and Butler 2008). During
movements of the body, nerves can undergo extremes of
elongation, for example the spinal canal is 5–9 cm longer
in flexion than extension, thus leading to an increased
tensile load on the spinal cord (Breig 1978; Louis 1981
cited in Butler and Gifford 1989). Another example is the
median nerve which has to adapt to a nerve bed nearly
20% longer if the shoulder is 90 degrees abducted, and
the wrist and elbow are moved from flexion to extension
(Millesi et al. 1986).
The nervous tissues are able to tolerate large tensile and
compressive forces during movements associated with
daily living and sporting activities. Nerves are strong struc-
tures owing to the surrounding connective tissue sheath
helping them withstand large compressive and tensile
forces (Shacklock 1995). If nerves are loaded by move-
ment they react by moving and absorbing some of the
pressure. During normal movement, as the nerve elongates
the perineurium tightens, intraneural pressure increases
8% elongation, with intraneural microcirculation ceasing
completely at 15% elongation (Ogata and Naito 1986).
As the nervous system is dynamic, forces that cause a
temporary disruption are easily tolerated. However, if the
load becomes too excessive or persists, the maintenance
of the increased local pressure to the nerve can cause local
tissue ischaemia and injury.
Pathophysiology of the  
nervous system
Injuries involving nervous structures can either be caused
by direct or indirect mechanics. A direct injury can occur
from over-stretching or irritation from a repetitious
561
 Tidy’s physiotherapy
activity, whereas an indirect injury can result from bleed-
ing owing to a muscle tear through which the nerve passes.
Either of these types of injury can cause extraneural dys-
function (affecting movements outside of the nerve; rela-
tive to the nerve) or intraneural dysfunction (affecting
movements within the nerve (Butler (1989)). These two
forms of dysfunction are not exclusive of one another and
sometimes extraneural dysfunction can actually lead to
intraneural dysfunction. Both, however, will be discussed
separately in further detail.
Extraneural dysfunction
The term ‘extraneural’ refers to anything outside of the
nerve. This refers to the ‘mechanical interface’, which is
any structure surrounding the nerves and lying between
them and other surrounding structures (Butler and Gifford
1989). The nervous system is surrounded by, and passes
through or around, various structures, including muscle,
bone, tendon, blood vessels and intervertebral discs.
These help contain the nervous system and allow for its
movement, so as the nerve shortens, elongates or twists
during daily movement so does the mechanical interface
(Shacklock 1995). The smooth and normal movement of
the nervous system and mechanical interface as it interacts
with the musculoskeletal system is important for injury
prevention. The consequence of extraneural pathology is
to subject the nerve to increased tensile, frictional or com-
pressive load. Examples of vertebral extraneural pathology
are the narrowing of the intervertebral foramina (e.g.
through osteophytes) or disc protrusions irritating a
nerve root. In the peripheral nervous system, examples of
extraneural pathology include the sciatic nerve lying in a
bed of blood from a hamstring tear, tight fascial bands
across nerves and a nerve as it passes through an oedema-
tous tunnel (tarsal tunnel, carpal tunnel).
During movements, nerves take their lead from the
movement of joints and muscles, needing to maintain a
dynamic relationship with all non-neural tissue. For
example, they must slide through tunnels of muscle and
fascia, and be compressed against various structures, such
as bone. Some interfacing structures make the nervous
system more vulnerable to injury like, for example, tunnels
(carpal tunnel, cubital tunnel, tarsal tunnel), hard inter-
faces (nerve on bone, passing through fascia), proximity
to the surface or when nerves are fixed to the interfacing
structures (e.g. common peroneal nerve at the fibular
head). With abnormalities in these interfacing tissues,
such as callus development, formation of bands of scar
tissue, pressure from haematoma or enlarging tumour or
ganglia, peripheral nerve neurodynamics and, therefore,
neurophysiology may be adversely affected.
Mechanical interface dysfunctions occur when the forces
exerted on the nervous system by the interfacing motion
segment are abnormal or undesirable. The pressure exerted
could be intermittent or sustained. These can be further
562
divided into either ‘opening’ or ‘closing’ dysfunctions. This
principle can be used throughout different neurodynamic
and musculoskeletal assessments. These dysfunctions can
be caused by, for example, incorrect posture, anatomical
abnormalities or undesirable technique/movement.
Key point
A closing dysfunction means an alteration in the closing
mechanism of the movement complex around the
nervous system. You can have either too much closing
(i.e. compression) or reduced closing.
Opening dysfunction involves an abnormality in the
opening mechanism of the movement complex located
adjacent to the nervous system. You can either have
increased opening or reduced opening function
(Shacklock 2005).
Intraneural dysfunction
Intraneural dysfunction refers to within the nerve itself.
Entrapment of a nerve by surrounding tissues or with an
intraneural fibrosis (scarring within the nerve structures)
can cause pathological changes within the nerve (Butler
and Gifford 1989). This may lead to a loss of range of
movement or alteration in elasticity of the nerve and, as a
result, enhance the normal mechano-sensitivity of the
nerve during movement and thus provoke pain and reac-
tive muscle spasm to prevent elongation.
Intraneural pathology can cause damage to the tissue of
the nervous system itself, either to the conducting tissue
in the form of demyelination, neuroma or hypoxia, or to
the surrounding connective tissue, for example scarring of
the epineurium. The possibility exists that a fibrosed nerve
can cause a friction fibrosis elsewhere in the system.
Tension has been taken up at one site in the nervous
system thereby compromising the amount of available
‘slack’ elsewhere in the system. An example is a fibrotic
length of common peroneal nerve at the head of fibular
that may lead to abnormal deep peroneal nerve/interface
relationships at the ankle. This may contribute to altered
proprioception input from the ankle and in combination
with less slack in the nervous system, influence the neuro-
logical functioning of the ankle joint, perhaps predispos-
ing to recurrent ankle ligament sprains.
Mechano-sensitivity
The term mechano-sentitivity refers to how easily a nerve
is activated following application of mechanical force
(Shacklock 2005). There are a variety of causes for
mechano-sensitivity; however, perhaps the most common
factor is owing to pressure. This can either be applied
directly or indirectly, as will be discussed.

Direct mechanical pressure can be applied to the nerve
by any tissue infringing the space occupied by the nerve
(e.g. ‘bulging disc’ or poorly fitted athletic knee brace). For
example, compression of a disc hernia reduces blood flow
in the nerve by 70% (Kobayashi et al. 2003). When loading
persists, as it could from sustained un-physiological pos-
tures or maintained local pressures, damage may ensue as
a result of local tissue ischaemia.
Indirect pressure is a more powerful cause of compres-
sive load and therefore mechano-sensitivity, and is caused
by immediate swelling in surrounding tissues that have
been damaged. This inflammatory response also results
in the release of chemical substances (histamines and
enzymes) which create a chemical irritation, increasing
pain, and can potentially lead to the laying down of scar
tissue in and around the nerve with long-lasting negative
effects on the mobility of the nerve.
Double and multiple crush
syndrome
Double (DCS) or multiple crush syndrome (MCS) refers
to a condition where proximal compression or elongation
of a nerve decreases the nerve’s ability to withstand
compression or elongation at a distal site (Upton and
McComas 1973). This type of condition is caused by
changes to the nerve’s axoplasmic flow. Axoplasmic flow
is the term used to describe the transport mechanism of
cell components in the nerve to their functional site where
they help to maintain tissue health. Therefore, any pres-
sure which is directly applied to the nerve or in the sur-
rounding tissue following injury may cause slowing down
of the axoplasmic flow and cause the nerve to ‘become
sick’. If pressure is applied to two (double crush) or mul-
tiple areas (multiple crush), the nerve will be considerably
more prone to injury.
Axoplasmic flow relies on a mechanically unimpeded
nervous system and an uninterrupted blood flow. Changes
in the flow characteristics of axoplasm could cause insidi-
ous attrition to both target tissues and neurones, and
impairment in the ultrastructure of the neurone. This
enables previously resistible compressive or tensile forces
to cause damage, usually at the vulnerable areas of the
nervous system outlined previously. For example, patients
with carpal tunnel syndrome are more likely to develop a
compression lesion of the ulnar nerve at Guyon’s canal
and those suffering from carpal tunnel syndrome fre-
quently have bilateral symptoms.
The original DCS described neural injuries at the
neck which then predisposed to carpal tunnel syndrome
(Upton and McComas 1973). Alternatively, reversed
DCS occurs where a distal neural injury (e.g. at the
wrist) predisposes to a proximal injury, perhaps at the
shoulder. MCS occurs where following initial neural injury
a patient experiences multiple and related areas of
Neurodynamics Chapter 25
symptoms. Clinical presentation of DCS or MCS may
often be widespread and unfamiliar in nature. However,
patients may complain of a string of injuries or multiple
areas of localised pain which have common pathophysi-
ologies that represent a minor form of DCS or MCS.
The concept of DCS or MCS therefore provides an excel-
lent reason for clinicians to evaluate along the nerve
tract when suspicious of a neurogenic lesion. This should
always be considered a possibility whenever an athlete
reports multiple areas of pain, for instance a distance
runner who complains of tibialis anterior and buttock
pain. If diagnosis is later confirmed as DCS or MCS, treat-
ment should also be considered for all the sites involved.
For the example of the distance runner, treatment of the
piriformis muscle may be needed to alleviate neural symp-
toms at the foot by altering a site of pressure contributing
to altered axoplasmic flow to the foot.
ASSESSMENT PRINCIPLES
Indications
The main purpose of neurodynamic testing is to load the
tested neural structures to help gain an understanding of
their mechanical function in relation to load and their
state of sensitivity to that load. There is no set indication
of when neurodynamic testing should be performed;
however, some believe that it should be performed if the
client presents with any form of neurological symptoms,
such as pins and needles, tingling, shooting or burning
pain, unexplained strength loss, paraesthesia or numb-
ness. Alternatively, neurodynamic testing may be indicated
for any overuse injury or reinjury, or if the client has
sustained an injury to the vertebral region. However, in
theory, neurodynamic testing could be considered for any
musculoskeletal injury as nerves are closely connected to
other structures (e.g. muscles, tendons and ligaments).
As well as indications, there are also contraindications
and precautions to neurodynamic testing. Contraindica-
tions represent any kind of factor or condition that increases
the risk or danger to cause serious harm to the client by
carrying out neurodynamic testing. Therefore, if any con-
traindications are present the neurodynamic tests should
not be carried out. Precautions are factors that you should
be aware of and take additional care of when carrying out
and interpreting neurodynamic tests, although this does
not mean that you cannot carry out the tests. Common
contraindications and precautions to neurodynamic
testing are presented in Table 25.1 (Butler 1989).
Structural differentiation
Neurodynamic tests involve assessing the mobility of the
nervous system as it interacts with the musculoskeletal
563
 Tidy’s physiotherapy

Table 25.1  Contraindications and precautions to neurodynamic testing

Contraindications Precautions

Recent onset/worsening of neurological Spinal stenosis or spondolythesis Dizziness (vertebrobasilar insufficiency)

signs

Cauda Equina lesions Disc protrusion Severe, unremitting pain

Cancer of nervous system/vertebral Presence of neurological signs Frank cord injury

column

Acute inflammatory infection Worsening disorder Circulatory disturbances

Osteoporosis resulting in abnormal Irritability of nervous system General health problems (diabetes,
interfacing tissues AIDS, multiple sclerosis)

Injury to spinal cord (tethered cord)

system. However, this can create a problem when trying to
distinguish whether reproductions of the client’s pain/
symptoms during a test is as a result of the movement by
nervous or musculoskeletal structures. Structural differen-
tiation emphasises movement of the neural tissues as
opposed to the musculoskeletal tissues, therefore helping
to identify the damaged structure – whether neural or
musculoskeletal (Butler 2000). For example, when per-
forming the slump test by extending the knee it would
cause movement, and potential tension, of both nervous
(sciatic nerve) and musculoskeletal (hamstrings) tissues.
To help distinguish which structure was the cause of
the client’s pain/symptoms, we could get the client to
release the cervical flexion. This structurally differentiating
manoeuvre is unlikely to alter the strain on the lower limb
musculoskeletal structures (hamstrings); however, it will
change the tension on the nervous system. Therefore, if
this manoeuvre resulted in reducing the client’s pain/
symptoms, we could propose that their injury was related
to neurological, rather than musculoskeletal, damage.
Sensitising manoeuvres
While structural differentiation is a key element for
helping identify neurogenic problems, for patients with a
Key point
Once an individual joint position is achieved make sure
this is maintained while other joints are moved during
the test.
Gain constant verbal and visual feedback from the
patient during testing.
Regularly re-test and monitor patient’s symptoms during
assessment and treatment and adapt as appropriate.
high level of function less severe problems may remain
hidden. Therefore, in order to make the test more specific
to identify the problem we can add sensitising manoeu-
vres. This is where the normal neurodynamic technique is
modified slightly to increase the test sensitivity so that it
becomes more specific to the patient’s problem (Keneally
et al. 1988). The easiest and most common way of sensi-
tising tests is to put extra strain, or stretch, on the nerve
by elongating it. A simple example of this would be to add
cervical flexion when performing a SLR. Another sensitis-
ing manoeuvre would be to contract a muscle close to
the nerve pathway around the affected area during the
neurodynamic test, such as contracting piriformis muscle
during SLR.
Clinical note
General rules when carrying out neurodynamic
assessment:
• explain to the patient what you are doing and what
they may feel during the test
• always carry out the test slowly
• do not only listen to the verbal feedback from the
patient but also feel the resistance during the
assessment
• do not hold the end position longer than you need
to. Once the end position is reached, release it and
ask the patient what they felt. In the worst case the
patient may not remember and you may have to
repeat the test
• always compare sides, testing the injured/affected
side last
• always ask about the nature and location of the test
responses

564

However, these manoeuvres cause a greater risk of pain
to the patient. Therefore, sensitising manoeuvres are only
recommended when previous standard neurodynamic
tests have not revealed enough information to make a
clear diagnosis and/or it is unlikely to cause severe pain/
reproduction of symptoms, and the patient has no persist-
ent or worsening neurological problems.
It is vital during neurodynamic assessment that the tests
are performed correctly by the clinician as ill-performed
tests can result in different responses by the client, there-
fore impairing accurate diagnosis of the injury. When cor-
rectly performing neurodynamic tests, it is important to
carefully observe how the patient responds at all times, the
available range of movement and the resistance felt by the
clinician. The following points are to be considered during
the neurodynamic test:
• the quality of the movement (e.g. is the movement
smooth and not jerky);
• the range of movement (similarity bi-laterally);
• resistance through range and at end-of-range (here,
the clinician may feel tightness that stops or impairs
the movement);
• pain and symptoms through range (this may or may
not be specific to reproducing their pain/symptoms).
Clinical note
Unlike other musculoskeletal tests the neurodynamic
tests do not always have a clear positive or negative, and
findings must be reflected upon in light of the bigger
patient picture.
INTERPRETATION OF FINDINGS
Early clinicians were taught to determine whether a test
was ‘positive’ or ‘negative’. However, when performing
neurodynamic tests it is highly likely that there is no clear-
cut positive or negative answer. The findings from the
neurodynamic examination must be clinically reasoned
using all the information gained throughout the complete
clinical assessment to make an informed decision of how
next to proceed with treatment relevant to the individual
patient’s problem. With this in mind, the patient’s response
to the neurodynamic testing can be divided into four
general categories, which are listed below.
• Optimal – this is where the neural system behaves
exactly the way it should, allows full range of
movement and does not produce any symptoms or
discomfort to the patient, even when high loads and
stress are applied.
Neurodynamics Chapter 25
• Suboptimal – the neural system here behaves less
well, allows slightly reduced range of movement and
may result in producing some symptoms in the
patient, although not necessarily until a high enough
load is applied to provoke the system.
• Normal – here, the patient is likely to have some
symptoms during the testing; however, the function
of the neural system (i.e. range of movement) is
considered to be within ‘normal’ values (although
these are not clearly established) or similar on
both sides.
• Abnormal – this is where the function of the neural
system is obviously outside the normal range and
the patient may have significant symptoms. This can
be caused by pathology or abnormalities in the
mechanics and physiology of the nervous tissues.
Therefore, as abnormalities do not always produce
symptoms, the ‘abnormal’ response can be further
divided into:
relevant – this would be a direct link whereby the
test has clearly caused the patient’s problem;
irrelevant – no causal link to the patient’s
problem.
Neurodynamic test responses can be summarised in an
algorithm as shown in Figure 25.1.
Normal neurogenic response
A normal neurogenic response is one where there is a
positive response to a structural differentiating manoeuvre
that is a change in range of motion or symptoms. This
change is very similar on both sides and does not provoke
symptoms.
Abnormal neurogenic response
An abnormal neurogenic response is one where there is a
positive response to a structural differentiating manoeuvre
that is a change in range of motion. This change is very
different between both sides and the test may or may not
provoke symptoms. If the test provokes symptoms it is
regarded as a relevant abnormal neurogenic response, i.e. there
is a structurally differentiated positive response which is
asymmetrical and provokes symptoms. The alternate to
this is an irrelevant abnormal neurogenic response. Here,
there is a structurally differentiated positive response
which is asymmetrical but does not provoke the patient’s
symptoms. There may, however, be a causal link between
this finding and the patient’s symptoms.
The test is positive when the patient gets an abnormal
neurogenic response. This is indicated by a change in
range of motion with structural differentiation as com-
pared with the non-affected side. Alongside the change
in range of movement with structural differentiation, the
test can also demonstrate symptom reproduction which is
altered by structural differentiation (relevant abnormal
565
 Tidy’s physiotherapy

Test

Positive Response to Negative

structural
differentiation?

Reasonably Yes Optimal

Normal
symmetrical response –
neurogenic
bilateral non-neural

No
Symptom No Irrelevant
reproduction? abnormal
neurogenic
Yes
Relevant
abnormal
neurogenic

Figure 25.1  Algorithm to interpret neurodynamic response to testing.

neurogenic response) or might not demonstrate symptom

reproduction (irrelevant abnormal neurogenic response). GENERAL TESTS
If you find an abnormal neurogenic response during the
test you only know that there is a neurodynamic dysfunc- In the following sections we describe the indications, tech-
tion (increased mechano-sensitivity) somewhere along niques and structural differentiation for the main neuro-
the nerve but you are not yet able to tell exactly what the dynamic tests.
cause for the dysfunction is and where exactly it is. The
subjective history may give you some indications as to
where the side of pathology may be.
What is causing increased mechano-sensitivity? It can Passive neck flexion
be decreased neural tissue mobility, inflammation of the
Indications
innervated tissue or mechanical interface dysfunction. You
can always assume there is a problem with neural tissue • Headaches.
mobility if there is mechano-sensitivity. We need to find • Pain in the upper limbs.
out if the mechanical interface contributes to this problem • Pain in the neck and shoulder area.
and/or the degree of inflammation within the innervated
tissue. Tissue inflammation can be identified by the typical
signs of inflammation (hot, red, swollen) and the loss of Technique
function related to recent injury. To identify the side of Start with the patient lying supine. Stand behind the
possible mechanical interface dysfunction further assess- patient and place one hand under the neck and the
ment is needed but it is not within the scope of this other hand on the forehead. Alternatively, have both
chapter to discuss this in detail. hands under the head (Figure 25.2). Move the head in
flexion.

Clinical note
Structural differentiation
• Sequencing – depending on the injury you might For structural differentiation a second therapist is needed
want to change the sequence of movements during for assistance. Once you have positioned the head in
the tests. maximum neck flexion, the second therapist carries out a
SLR as described later.

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 Neurodynamics Chapter 25

Slump test
Indications
• Pain and altered sensation related to nerve roots
L4–S3.
• Muscle dysfunction (weakness or overactivity)
in myotomes supplied by these nerve roots
(foot dorsiflexion, extension hallux, eversion of
the foot, contraction buttock, knee flexion, toe
standing).
• Pain in the area of the sensory supply of the sciatic,
tibial or peroneal nerve.
• Muscle dysfunction (weakness/overactivity) of
the muscles supplied by the sciatic nerve
(semitendinosus, semimembranosus, biceps femoris, Figure 25.2  Hand positioning during passive neck flexion.
hamstring part of adductor magnus), tibial nerve
(gastrocnemius, soleus, plantaris, popliteus, tibialis
posterior, flexor digitorum longus, flexor hallucis
longus) or peroneal nerve (peroneus longus and
brevis, extensor digitorum longus, tibialis anterior,
extensor hallucis longus, peoneus tertius, extensor
digitorum brevis).
• Symptoms related to sitting, driving, sprinting,
hurdling, kicking and bending.
• Pathologies such as lumbar spine pathologies,
sacroiliac joint pathologies, hamstring and calf
muscle strains, Achilles, peroneal and tibial
tendon injuries, ankle ligament sprains and
plantar fasciitis.

Technique
Start the test with the patient sitting on the edge of a
plinth with their spine in a neutral position, their sacrum
vertical and their hands behind their back. Then, get the Figure 25.3  Neck and thoracic flexion during slump.
patient to slump forward so that their thoracic and
lumbar spine is flexed but still with their head looking
up and the sacrum vertical (neutral). Next, ask the patient
to flex their neck so that they bring their chin to their
chest. Place your hand over the top of their head and
your elbow on the thoracic spine to maintain this posi-
tion (Figure 25.3). Now, ask the patient to actively extend
their knee until the end of range (Figure 25.4), and then
dorsiflex their ankle also to end-of-range or to when
they indicate a reproduction of pain/symptoms (Figure
25.5). Finally, remove your hand from the patient’s head
and ask them to look up (Figure 25.6). This is your
structural differentiation manoeuvre. If neural tissue
is involved the symptoms are changing (either reducing
or increasing).

Sensitising manoeuvre
You can sensitise the test by getting the patient to put their
foot into plantar flexion and inversion instead of dorsi-
flexion (sensitises for the common peroneal nerve). Figure 25.4  Knee extension during slump.

567
 Tidy’s physiotherapy
Figure 25.5  Ankle dorsiflexion during slump.
Figure 25.6  Structural differentiation for slump.
LOWER LIMB NEURODYNAMIC TESTS
(LLNTs)
Straight leg raise test (SLR)
Indications
• Pain and altered sensation related to nerve roots
L4–S3.
• Muscle dysfunction (weakness or overactivity) in
myotomes supplied by these nerve roots (foot
dorsiflexion, extension hallux, eversion of the foot,
contraction buttock, knee flexion, toe standing).
568
• Pain in the area of the sensory supply of the sciatic,
tibial or peroneal nerve.
• Muscle dysfunction (weakness/overactivity) of
the muscles supplied by the sciatic nerve (semi-
tendinosus, semi-membranosus, biceps femoris,
hamstring part of adductor magnus), tibial nerve
(gastrocnemius, soleus, plantaris, popliteus, tibialis
posterior, flexor digitorum longus, flexor hallucis
longus) or peroneal nerve (peroneus longus and
brevis, extensor digitorum longus, tibialis anterior,
extensor hallucis longus, peoneus tertius, extensor
digitorum brevis).
• Symptoms related to sitting, driving, sprinting,
hurdling, kicking and bending.
• Pathologies such as lumbar spine pathologies,
sacroiliac joint pathologies, hamstring and calf
muscle strains, Achilles, peroneal and tibial tendon
injuries, ankle ligament sprains and plantar fasciitis.
Generally, the slump test is used because it puts greater
mechanical load on neural tissues and so allows for greater
sensitivity. SLR might be chosen over the slump test
if tissue is perceived to be highly irritable and sensitive
to load.
Technique
Start the test with the patient lying supine. Stand to the
side of the patient you are about to perform the test on,
facing towards their head. Place one hand just above their
knee and the other under their Achilles tendon with your
palm over their foot (Figure 25.7). Perform the test by
lifting their leg, bringing their hip into flexion while main-
taining the extended knee until the end-of-range or until
the patient indicates a reproduction of pain/symptoms
(Figure 25.8).
Structural differentiation
Add structural differentiation by getting the patient to side
flex their trunk to the contralateral side (Figure 25.9).
Sensitising manoeuvre
You can sensitise the test by adding plantar flexion and
inversion of the foot (sensitises for the common peroneal
nerve) or adding ankle dorsiflexion (sensitises for the
tibial nerve).
Modifications of SLR: peroneal, sural
and tibial nerve test
Indications
• Pain and altered sensation related to nerve roots
L4–S3.

Figure 25.7  Hand positioning during straight leg raise.
Figure 25.8  Straight leg raise.
• Muscle dysfunction (weakness or overactivity) in
myotomes supplied by these nerve roots (foot
dorsiflexion, extension hallux, eversion of the foot,
contraction buttock, knee flexion, toe standing).
• Pain in the area of the sensory supply of the tibial,
sural or peroneal nerve.
• Muscle dysfunction (weakness/overactivity) of the
muscles supplied by the tibial nerve (gastrocnemius,
soleus, plantaris, popliteus, tibialis posterior, flexor
digitorum longus, flexor hallucis longus) or peroneal
nerve (peroneus longus and brevis, extensor
digitorum longus, tibialis anterior, extensor hallucis
longus, peoneus tertius, extensor digitorum brevis).
• Symptoms related to sitting, driving, sprinting,
hurdling, kicking and bending.
• Pathologies such as lumbar spine pathologies,
sacroiliac joint pathologies, hamstring and calf
muscle strains, Achilles, peroneal and tibial tendon
injuries, lateral ankle ligament sprains and plantar
fasciitis.
Neurodynamics Chapter 25
Figure 25.9  Structural differentiation for straight leg raise.
Figure 25.10  Foot position peroneal neurodynamic test.
Technique
Peroneal
Start the test with the patient lying supine. Stand to the
side of the patient you are about to perform the test on,
facing towards their feet and place one hand just above
their knee. Reach with the other hand under their foot,
placing your fingers on their toes to bring the foot into
plantar flexion and inversion (Figure 25.10). Perform the
test by lifting their leg, bringing their hip into flexion while
maintaining the extended knee and plantar flexed/inverted
foot until the end-of-range or the patient indicates a repro-
duction of pain/symptoms.
Sural
Start the test with the patient lying supine. Stand to the
side of the patient you are about to perform the test on,
facing towards their feet and place one hand just above
their knee. Place the other hand around their foot and
bring the foot into dorsiflexion, inversion position.
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 Tidy’s physiotherapy

Perform the test by lifting their leg, bringing their hip

into flexion while maintaining the extended knee and
dorsiflexed/inverted foot until the end-of-range or the
patient indicates a reproduction of pain/symptoms.

Tibial
Start the test with the patient lying supine. Stand to the
side of the patient you are about to perform the test on,
facing towards their feet and place one hand just above
their knee. Place the other hand around their foot and
bring the foot into dorsiflexion, eversion position. Perform
the test by lifting their leg, bringing their hip into flexion
while maintaining the extended knee and dorsiflexed/
everted foot until the end-of-range or the patient indicates
a reproduction of pain/symptoms. Figure 25.11  Starting position prone knee bend.

Structural differentiation for peroneal, sural

and tibial neurodynamic test
Add structural differentiation by getting the patient to side
flex their trunk to the contralateral side.

Prone knee bend

Indications
• Pain and altered sensation related to nerve roots
L2–L4.
• Muscle dysfunction (weakness or overactivity) in
myotomes supplied by these nerve roots (hip flexion,
knee extension, foot dorsiflexion).
• Pain in the area of the sensory supply of the femoral
nerve.
• Muscle dysfunction (weakness/overactivity) of the
muscles supplied by the femoral nerve (iliacus,
sartorius, quadriceps femoris).
• Symptoms related to iliac crest area pain, groin pain, Figure 25.12  End position prone knee bend.
hip pain (anterior), thigh pain and knee pain.
• Pathologies such as higher lumbar spine pathologies,
hip pathologies, groin and quadriceps muscle strains
and anterior knee pain.
UPPER LIMB NEURODYNAMIC  
Technique TESTS (ULNTs)
Start the test with the patient lying on their front (referred
to as ‘prone’). Place one hand under their thigh, just above Median neurodynamic test 1  
the knee or on the sacrum, and the other hand around (MNT1 or ULNT1)
their ankle (Figure 25.11). Then, bring their knee into
flexion until end-of-range or the patient indicates a repro- Indications
duction of pain/symptoms (Figure 25.12). • Pain and altered sensation related to nerve roots
C5–T1.
• Muscle dysfunction (weakness or overactivity) in
Structural differentiation myotomes supplied by these nerve roots (shoulder
Add structural differentiation by getting them to side abduction, elbow flexion, elbow extension, finger
flex their trunk to the contralateral side (Figures 25.13 flexion, finger abduction and adduction, thumb
and 25.14). extension).

570

Figure 25.13  Starting position prone knee bend with
structural differentiation.
Figure 25.14  End position prone knee bend with structural
differentiation.
• Pain or altered sensation in the area of the sensory
supply of the median nerve.
• Muscle dysfunction (weakness/overactivity) of the
muscles supplied by the median nerve (pronator
teres, flexor carpi radialis, palmaris longus, flexor
digitorum superficialis, abductor pollicis brevis,
flexor pollicis brevis, opponens pollicis, flexor
pollicis longus).
• Symptoms related to throwing or reaching.
• Pathologies such as neck pathologies, whiplash,
shoulder dislocations/subluxations, golfer’s elbow
(medial epicondylitis), pronator tunnel related
pathology and carpal tunnel syndrome.
Technique
Facing the supine lying patient, place your elbow superior
to their shoulder and gripping the lateral side of their
elbow with the hand of the same arm. With the other
hand take hold of the patient’s wrist and hand to place the
Neurodynamics Chapter 25
Figure 25.15  Starting position median neurodynamic test 1.
Figure 25.16  Shoulder abduction during median
neurodynamic test 1.
wrist and fingers in full extension. Using your elbow,
which is placed over their shoulder, depress their scapula
to a neutral position by pulling it downwards towards
their feet (caudad direction) (Figure 25.15). Now, take
their shoulder into 90 degrees abduction and bring their
forearm into supination (Figure 25.16). Next, place
the shoulder in lateral rotation (Figure 25.17) and com-
plete the test by extending their elbow until the end of
range or they indicate a reproduction of pain/symptoms
(Figure 25.18).
Structural differentiation
There are two different ways of carrying out structural
differentiation to MNT1. The first technique requires
you to carry out MNT1 as described above. When the end
position in terms of elbow extension is reached, ask the
patient to side flex the neck to the contralateral side
(Figure 25.19). If neural tissue is involved, you may expect
an increase or a decrease in the intensity of the symptoms
571
 Tidy’s physiotherapy

and more resistance. If there is no neural tissue involve-

ment, the symptoms will not change.
The other way is to place the head in contralateral lateral
flexion prior to carrying out MNT1 as described above.
Once the end position is reached ask the patient to bring
the head back into a neutral position. If there is neural
tissue involvement the intensity of the symptoms and
resistance may reduce or increase and you may be able to
move the elbow a bit more in extension. If there is no
neural tissue involvement you will not find any change.

Median neurodynamic test 2  

Figure 25.17  Shoulder lateral rotation during median
neurodynamic test 1.
Figure 25.18  End position median neurodynamic test 1.
(MNT2 or ULNT2A)
Indications
• Pain and altered sensation related to nerve roots
C5–T1.
• Muscle dysfunction (weakness or overactivity) in
myotomes supplied by these nerve roots (shoulder
abduction, elbow flexion, elbow extension, finger
flexion, finger abduction and adduction, thumb
extension).
• Pain in the area of the sensory supply of the median
nerve.
• Muscle dysfunction (weakness/overactivity) of the
muscles supplied by the median nerve (pronator
teres, flexor carpi radialis, palmaris longus, flexor
digitorum superficialis, abductor pollicis brevis,
flexor pollicis brevis, opponens pollicis, flexor
pollicis longus).
• Symptoms related to underarm throwing, reaching
behind, falling onto outstretched hand and pulling
objects (dog-walking).
• Pathologies such as neck pathologies, shoulder
dislocations/subluxations, golfer’s elbow (medial
epicondylitis), pronator tunnel related pathology
and carpal tunnel syndrome.

Technique
With the patient lying supine and slightly obliquely on the
bed, stand at the top corner of the bed, depress their
scapula by leaning your hip against their shoulder, adding
slight pressure. Place one hand under their elbow (flexed
to 90 degrees) and take the arm into slight abduction.
With the other, hold their hand so that you take their
forearm into supination while extending their wrist and
fingers (Figure 25.20). Next, fully extend their elbow and
laterally rotate their shoulder (Figure 25.21). Finally,
abduct and extend their shoulder until the end of range
(Figure 25.22).

Structural differentiation
Figure 25.19  Structural differentiation for median Structural differentiation can be carried out in the same
neurodynamic test 1. way as for MNT1.

572

Figure 25.20  Starting position median neurodynamic test 2.
Figure 25.21  Mid-position median neurodynamic test 2.
Figure 25.22  End position median neurodynamic test 2.
Neurodynamics Chapter 25
Ulnar neurodynamic test  
(UNT or ULNT3)
Indications
• Pain and altered sensation related to nerve roots
C8–T1.
• Muscle dysfunction (weakness or overactivity) in
myotomes supplied by these nerve roots (finger
flexion, thumb extension, finger abduction and
adduction).
• Pain in the area of the sensory supply of the ulnar
nerve.
• Muscle dysfunction (weakness/overactivity) of the
muscles supplied by the ulnar nerve (flexor carpi
ulnaris, flexor digitorum profundus, palmaris brevis,
abductor, flexor and opponens digiti minimi, medial
two lumbricales, palmar and dorsal interossei,
adductor pollicis).
• Symptoms related to overarm throwing, reaching
overhead and breast stroke swimming.
• Pathologies such as neck pathologies, shoulder
dislocations/subluxations, climber’s elbow and
golfer’s elbow (medial epicondylitis).
Technique
Start the test with the patient lying supine, place your
hand on the scapula. Begin the test by pulling their
scapula downwards, in the direction of their feet, to
cause it to depress. Then, slightly abduct the patient’s
shoulder (to around 30 degrees) and flex their elbow to
90 degrees. Next, bring the patient’s forearm into prona-
tion while maximally extending their wrist and fingers
(Figure 25.23). Now, laterally rotate their shoulder to 90
degrees and abduct it (Figure 25.24). Finally, maximally
flex their elbow and further abduct their shoulder so
that you bring their hand towards their ear until the
end of range or they indicate a reproduction of pain/
symptoms (Figure 25.25). It is important not to let the
shoulder elevate during this test.
Structural differentiation
Structural differentiation can be carried out in the same
way as for MNT1 and MNT2 by applying contralateral
lateral flexion (Figure 25.26).
Radial neurodynamic test  
(RNT or ULNT2)
Indications
• Pain and altered sensation related to nerve roots
C5–T1.
• Muscle dysfunction (weakness or overactivity) in
myotomes supplied by these nerve roots (shoulder
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 Tidy’s physiotherapy
Figure 25.23  Starting position ulnar neurodynamic test.
Figure 25.24  Mid-position ulnar neurodynamic test.
Figure 25.25  End-position ulnar neurodynamic test.
574
Figure 25.26  Structural differentiation for ulnar
neurodynamic test.
abduction, elbow flexion, elbow extension, finger
flexion, finger abduction and adduction and thumb
extension).
• Pain in the area of the sensory supply of the radial
nerve.
• Muscle dysfunction (weakness/overactivity) of the
muscles supplied by the radial nerve (triceps,
anconeus, brachialis, brachioradialis, extensor carpi
radialis longus, supinator, extensor carpi radialis
brevis, estensor digitorum, extensor digiti minimi,
extensor carpi ulnaris, extensor pollicis longus and
brevis, extensor indicis, abductor pollicis longus).
• Symptoms related to throwing (follow through),
tennis backhand, swimming (breast stroke, front
crawl and butterfly) and golf.
• Pathologies such as neck pathologies, shoulder
dislocations/subluxations and tennis elbow (lateral
epicondylitis).
Technique
With the patient in the same position as for MNT2, lying
supine obliquely across the plinth, stand at the top corner
of the bed and depress their scapula by leaning your hip
against their shoulder adding slight pressure. Then, abduct
their shoulder slightly and, holding their hand, take their
forearm into pronation while flexing their wrist and
fingers (Figure 25.27). Next, fully extend their elbow and
medially rotate their shoulder (Figure 25.28). Finally,
abduct and extend their shoulder until the end of range
(Figure 25.29).
Structural differentiation
Structural differentiation can be carried out in the same
way as for the median (MNT 1 and MNT 2) and ulnar
neurodynamic test.

Figure 25.27  Starting position radial neurodynamic test.
Figure 25.28  Mid-position radial neurodynamic test.
Figure 25.29  End position radial neurodynamic test.
Neurodynamics Chapter 25
TREATMENT PRINCIPLES
General rules when carrying out
neurodynamic treatment
• Always carry out the movements slowly;
• After one set of treatments, reassess;
• Do not continue with the same treatment if
symptoms or signs worsen on reassessment.
Basically, there are three different treatment approaches
once a neurodynamic dysfunction has been identified:
neural tissue mobility, inflammation of the innervated
tissue or mechanical interface dysfunction. The optimum
treatment obviously links to what you find during the
assessment.
This section will focus on treating neural tissue mobility.
In brief, inflammation of the innervated tissue can be
treated by the usual modalities to reduce inflammation,
for example ice and anti-inflammatory drugs, but of great-
est impact will be to ‘offload’ the nerve and rest it. Offload-
ing means to avoid positions where the nerve is elongated
or interface tissue is in a position where it does not com-
press the nerve. The mechanical interface treatment applies
where peripheral nerves pass through numerous interfaces
(e.g. muscles, intervertebral foramen, tunnels), each of
which can influence the mechano-sensitivity of the nerve.
These different structures should be treated appropriately
with, for example massage, stretching and mobilisation
techniques. It is beyond the scope of this chapter to discuss
the treatment of these interfaces.
Clinical note
• Interface treatment – neurodynamic treatment does
not only involve mobilisation of the nerve. The
interfaces the nerves pass through directly influence
nerve mobility; therefore, treating neurodynamic
dysfunctions also has to involve the treatment of the
interfaces the nerves pass through and relate to.
Neural tissue mobility
To have an optimum function, nerves need to be able to
move freely within the nerve bed, as well as in relation to
the surrounding tissues. If the movement is impaired, cir-
culation is also frequently compromised. One technique
to increase sliding mobility, as well as circulation, is a
so-called ‘slider’.
To carry out sliders, nerves need to be brought into a
position where the slack is taken up, meaning that some
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 Tidy’s physiotherapy

tension needs to be applied to the nerve before starting

Neurodynamic
the sliding movement. The sliding movement should treatment
be carried out in mid-range, avoiding positions where progression
the nerve is put into too much tension. The sliding move-
ment can be carried out in one joint (one-ended slider)
or in two joints at the same time (two-ended slider).
The general rule is that to start a treatment the joint fur- 2-ended slider 1-ended slider
thest away from the area of the injury is moved. This
means, for example, if somebody has a shoulder injury,
your slider treatment would start with moving the fingers 1-ended tensioner 2-ended tensioner
or wrist.
For the two-ended sliders, you are moving two joints at
the same time. One joint will be in the position where the
Activity-specific
nerve is elongated and the other joint is placed in the positions
position where the nerve is shortened. During movement,
the first joint changes into a position where the nerve is
shortened and the other joint into a nerve-lengthening
position. Progress sliders to
Tensioners aim to decrease the mechano-sensitivity tensioners
of a nerve. This means getting the nerve used to mechani-
cal tension without reacting to it and to increase the Figure 25.30  Progression of treatment.
visco-elastic properties of the nerve. This involves bringing
the nerve into an elongated position (end-range move-
ment), holding this position for a short period of time Progression of treatment neural dysfunction
and then completely releasing the tension. Similar to To progress treatment the following steps can be taken:
sliders there are one- and two-ended tensioners, with one-
• offloading position;
ended tensioners being when load is applied to one
• move from two-ended sliders through to one-ended
end of the nerve bed and two-ended tensioners being
sliders into one-ended tensioners to two-ended
when the two ends of the nerve are taken away from
tensioners;
each other, simultaneously elongating the nerve from
• increase the range of movement during sliders or
two ends. If tensioners are evoking symptoms such as
tensioners in relation to the relevant treatment barrier;
numbness, tingling, pins and needles, carry out sliders
• increase the number of repetitions;
to increase circulation and to reduce these symptoms.
• increase the number of sets;
A general rule for slider and tensioner treatment is
• move joint/s closer to the area of the injury;
that if the injury is in a joint, you do not move this joint
• carry out neural mobilisation techniques in sport or
but leave it in a neutral position that is comfortable for
functionally-related positions (Figure 25.30).
the client. If the injury is in a muscle, you can move the
joints either side of the muscle as slider and tensioner
treatment. Key point
The number of repetitions and sets of sliders and ten-
sioners depends on the client response to the treatment Caution: assessment and treatment can irritate the patient.
and how acute the injury is. Always ensure you are retest- The patient must be aware of the potential for flare-ups
ing after the first set of treatment to evaluate. Adapt your and how to deal with them (offloading position, etc.).
treatment according to the client’s reaction.

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 Neurodynamics Chapter 25

CASE STUDIES
TYPICAL SCENARIOS WHEN NEURODYNAMIC
TESTING AND TREATMENT IS UNDERTAKEN
CASE STUDY 1
Patient presents reporting tingling and sometimes pins
and needles at the antero-lateral lower leg. This started
after playing netball without any trauma. Slump, SLR and
peroneal test were positive; tibial test was negative.
Treatment: 3 × 10 two-ended sliders of peroneal nerve
showed some immediate improvement. Continued with 3
× 10 one-ended sliders in combination with interface
treatment of the peronei muscles and the problem was
resolved.
CASE STUDY 2
Patient presents following a hamstring ‘strain’ playing
football. He has pain on resisted knee flexion and local
tenderness in the lateral hamstring on palpation. SLR
showed reduced range and was painful; structural
differentiation was positive. After 3 × 20 two-ended
sliders, SLR had full strength with slight ache on resisted
knee flexion; SLR range significantly improved.
CASE STUDY 3
Patient presents with a tennis elbow which is not
responding to conventional treatment of ultrasound,
deep transverse friction massage and stretching. Radial
neurodynamic test was positive on structural
differentiation. Treatment of 2 × 10 one-ended sliders and
2 x 10 tensioners was successful and radial neurodynamic
test was negative.

REFERENCES

Breig, A., 1978. Adverse Mechanical
Tension in the Central Nervous
System. Almqvist and Wiksell,
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Butler, D.S., 1989. Adverse mechanical
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A model for assessment and
treatment. Aust J Physiother 35 (4),
225–238.
Butler, D.S., 1991. Mobilisation of
the Nervous System. Churchill
Livingstone, Edinburgh.
Butler, D.S., 2000. The Sensitive
Nervous System. Noigroup
Publications, Australia.
Butler, D.S., Gifford, L., 1989.
The concept of adverse
mechanical tension in the
nervous system. Physiotherapy
75 (11), 622–629.
Coppieters, M.W., Butler, D.S., 2008.
Do ‘sliders’ slide and ‘tensioners’
tension? An analysis of
neurodynamic techniques and
considerations regarding their
application. Man Ther 13 (3),
213–221.
Keneally, M., Rubenach, H., Elvey, R.,
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The SLR of the arm. In: Grant, R.
(Ed.), Physical Therapy of the
Cervical and Thoracic Spine.
Churchill Livingstone, New York,
pp. 167–194.
Kobayashi, S., Shizu, N., Suzuki, Y.,
et al., 2003. Changes in nerve root
motion and intraradicular blood
flow during an intraoperative
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Michael-Titus, A., Revest, P., Shortland,
P., 2007. The Nervous System. Basic
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Churchill Livingstone, Edinburgh.
Millesi, H., Zoech, G., Reihsner, R.,
1986. Mechanical properties of
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Res 314, 76–83.
Ogata, K., Naito, M., 1986. Blood flow of
peripheral nerve effects of dissection,
stretching and compression. J Hand
Surg 11 (1), 10–14.
Shacklock, M., 1995. Neurodynamics.
Physiotherapy 81 (1), 9–16.
Shacklock, M., 2005. Clinical
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 Chapter
Neurological physiotherapy
Christine Smith, Anita Watson and Louise Connell
INTRODUCTION
Neurology is a specialised field that deals with disorders
of the nervous system. There are a vast number of neuro-
logical conditions that can affect the central nervous
system (CNS – brain and spinal cord), the peripheral
nervous system and the autonomic nervous system. The
challenges facing physiotherapists working in the clinical
field of neurology are many and varied. The complex
nature of the human nervous system and the broad range
of neurological conditions found in clinical practice place
heavy demands on physiotherapists. The onset of a neu-
rological condition as a result of disease or trauma has a
devastating effect not only on the patient but also on their
families. It is essential that any approach to management
encompasses the needs of all parties. Many neurological
conditions are progressive and longstanding, and result in
some element of residual impairment. There are numer-
ous challenges in the rehabilitation process from early
diagnosis and treatment through to discharge. The long-
standing nature of many neurological conditions means
that professionals are involved in the management and
rehabilitation of patients over a number of years.
An emerging evidence base surrounding the issues of
neurological rehabilitation means that the role of the
physiotherapist in treating and managing neurological
conditions is developing. Current research identifies
the importance of task-specific, strength and repetitive
training. Alongside this the use of novel interventions,
such as functional electrical stimulation (FES) and
constraint-induced movement therapy (CiMT) are advo-
cated. Research has shown that no one treatment approach
is superior to any other; instead, practitioners need to
select the most appropriate intervention based on the
available evidence base. Neurological damage can result
in the disruption of normal physical, psychological, cogni-
tive and social functions, which reinforces the need for
a collaborative and co-ordinated approach from a wide
range of rehabilitation professionals. It is vital that a truly
26 
holistic approach to the management and treatment of
patients and their families be adopted, with clinical rea-
soning and problem-solving at its centre. Practitioners
need to understand both the patients’ and carers’ perspec-
tive. Research has shown that therapists’ and patients’
goals often differ. As such, measurement of outcome is an
important aspect of neurological rehabilitation. The
chapter provides a section on outcome measurement and
goal-setting in relation to the International Classification
of Function (ICF) framework set out by the World Health
Organization (WHO) in 2001. The most appropriate
measures have been selected based on their psychometric
properties. Readers should refer to Tyson et al. (2008) for
further information.
This chapter begins by outlining the principal causes of
neurological damage and then describes types of move-
ment disorders and the most frequently encountered
clinical features. The clinical features have been grouped
together into categories to aid cross reference within the
assessment process. Physiotherapy assessment and the
main evidence-based interventions are then discussed in
relation to present-day clinical practice. A new section on
promising interventions that use rehabilitation technolo-
gies has been included to demonstrate their growing use
in healthcare practice. The chapter concludes with an over-
view of the more commonly known neurological condi-
tions, namely stroke, multiple sclerosis, motor neurone
disease and traumatic brain injury (Figure 26.1). These
sections are not intended to be exhaustive and readers can
consult the lists of further recommended reading at the
end of the chapter.
Further reading
Although neurological rehabilitation remains a new
science in comparison with some other subject areas
there is now an emerging evidence base for the types of
interventions practitioners should be considering. Readers
are directed to Shumway-Cook and Woollacott (2007).
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 Tidy’s physiotherapy

Frontal results in temporary inflammation processes occurring

eye field Sensorimotor area and, therefore, repairable or permanent damage (if there
Frontal lobe has been destruction of nerve tissue). Diseases can affect
the nervous system and some seem to have an affinity for
Prefrontal Parietal lobe a particular part of the system. Examples of diseases that
area
can affect the nervous system are meningitis, syphilis, and
(less commonly) tuberculosis and poliomyelitis. Diseases
Visual of unknown origin that affect the CNS include multiple
sclerosis and motor neurone which are discussed later in
the chapter.
Congenital defects, such as spina bifida, inherited con-
ditions, such as Huntington’s chorea, spinocerebellar
ataxia, vitamin B deficiency and neoplasms, and toxic sub-
stance poisoning, such as lead, arsenic and mercury, can
all also have a detrimental effect on the nervous system.
Broca’s area Temporal However, these are less common occurrences and there-
(in left hemisphere) lobe Visual fore will not be covered within this chapter. Peripheral
association neuropathies and fibromyalgia are also not covered.
Auditory
Auditory association Clinical features of damage to  
(including Wernicke’s
area, in left hemisphere) the CNS
Figure 26.1  Brain. Movement disorders
The result of abnormal tone, altered motor control and
impaired sensory input will lead to what is known as a
Background knowledge movement disorder. Day-to-day functions, such as walking,
dressing and eating, become difficult to perform owing
Readers are advised to refer to appropriate literature for to movements becoming un-coordinated, uncontrollable
details of the anatomy of the CNS in relation to its and involuntary. Common movement disorders are listed
function. A thorough understanding of the structure and below and can be seen with conditions such as stroke,
function of the CNS and the neural control of movement multiple sclerosis and Parkinson’s (see Chapter 24).
will be needed to effectively manage patients with
complex neurological conditions. Ataxia
Movements are un-coordinated and jerky. Functional
activities like walking look unsteady and arm movements
are difficult to control leading to overshooting or under-
Glossary shooting of the hand to a target. Ataxia is found as a result
of damage to the cerebellum, sensory and vestibular
Towards the end of this chapter is a glossary of some of systems.
the terms used within neurology.
Dystonia (previously known as athetosis)
Movements produced are writhing, slow and lead to
abnormal sustained postures being adopted. Generalised
dystonia may produce gross movements of the arms and
THE FUNDAMENTALS OF   legs. Focal dystonias usually involve the eyes, neck or
CNS DAMAGE upper limbs. They are thought to occur as a consequence
of damage to the basal ganglia. There may also be disrup-
Principal causes of neurological tion in facial and tongue movements. It is thought that
these movements may be owing to a disturbance in recip-
damage rocal inhibition.
The most commonly occurring neurological conditions
are those that occur as a result of problems within the Chorea
circulatory system, namely stroke (see later section). Other Movements are jerky but tend to occur more randomly
causes of neurological damage include trauma, as in head throughout the body. The absence of sustained abnormal
injury or spinal injury, where direct or indirect trauma posturing distinguishes this condition from dystonia.

580

Ballismus
Movements are large and sudden, and can affect one side
of the body (hemiballismus).
Tremor
Movements are fine, rapidly oscillating and unwanted.
Tremors are often classified in relation to the circum-
stances in which they occur, such as an intention tremor
which is found when a movement of a limb is made
towards a target. Many other tremors are known but will
not be covered in this chapter.
Bradykinesia
Movements are slow. This disorder is commonly seen in
Parkinson’s (see Chapter 24).
Impairments
The signs and symptoms of damage or disease to the
CNS are commonly known as clinical features. These
clinical features are also described as impairments when
using the ICF classification of functioning, disability and
health (ICFDH – see later section). The site and severity
of disruption to the CNS will determine which impair-
ments are seen. However, because the CNS is integrative,
damage to one part can result in a disruption of function
of other parts. This means that the site of damage alone
is not necessarily a predictor of the impairments the
patient will present with. For the purpose of classification,
impairments will be considered under the headings of
motor impairments, sensory impairments, visual impair-
ments, congnitive impairments, behavioural changes,
perceptual disturbances, auditory disturbances, communi-
cation disturbances/swallowing, fatigue, bladder/bowel
incontinence and automatic disturbances.
Motor impairments
Damage to neural motor pathways or motor cortex areas,
and direct muscle damage will lead to a loss or limitation
in muscle function.
• Muscle weakness and/or atrophy – a reduction in muscle
strength of a single muscle or groups of muscles.
Weakness can be specific to a side, such as hemiplegia,
or be generalised as a result of a person no longer
performing physical activities (deconditioned).
Atrophy describes muscle loss owing to lack of use.
• Muscle tone – this is the ‘state of readiness’ of an
individual’s muscles at rest. It is vital for maintaining
posture. The continuous small adjustments of the
muscle sensory receptors (muscle spindles and Golgi
tendon organs (GTOs) prepare the muscles for
movement). Muscle tone can become increased
(hypertonic) or decreased (hypotonic) depending on
the amount of information being sent to the muscle
receptors. This means that damage to the CNS can
result in altered muscle tone.
Neurological physiotherapy Chapter 26
• Spasticity – is ‘a motor disorder, characterised by a
velocity-dependent increase in tonic stretch reflexes
(muscle tone) with exaggerated tendon jerks,
resulting from hyper-excitability of the stretch reflex
as one component of the upper motor neurone
(UMN) syndrome’ (Lance 1980).
• Hypotonia – is low muscle tone. Muscle receptors are
unprepared for movement resulting in resistance-free
movement and weakness of muscles.
• Rigidity – is an increase in muscle tone which leads
to a resistance in passive movement. There are two
types commonly found in Parkinson’s:
 lead pipe rigidity manifests as a uniform
resistance to movement throughout the range of
movement;
 cogwheel rigidity presents as an intermittent on/
off resistance throughout the range of movement,
making the movements jerky.
Sensory impairments
Damage to the sensory receptors, sensory cortex areas or
pathways carrying sensory information, such as touch,
joint position and pain, will result in the following:
• altered cutaneous sensation – the skin sensation can
become diminished (anaesthesia), absent
(parasthesia) or more sensitive (hyperaesthesia) to
inputs such as light and deep touch, pressure,
vibration and two-point discrimination;
• altered proprioception – the muscle sensory receptors
(muscle spindles and GTOs) are unable to provide
information about a joint’s position. This means
that an individual may be unable to recognise what
position a body part is in;
• pain – damage to nerve endings and/or pain
pathways, as well as pain caused by secondary
complications, such as malalignment of joints
(owing to swelling or poor positioning of soft tissue
structures) will result in pain.
Visual impairments
Damage to the visual cortex area, optic nerve and motor
pathways controlling muscle function of the ocular system
will result in the following:
• hemianopia – loss of vision in half of the visual field
of each eye;
• diplopia – double vision;
• nystagmus – un-coordination of the eye muscles
leading to fast or slow alternating movements of the
eye when asked to move them or hold them on a
target.
Cognitive impairments
Damage to the parietal lobe can lead to loss in the ability
to process, learn and remember information:
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 Tidy’s physiotherapy
• attention;
• memory;
• learning;
• emotional changes.
Damage to the limbic system can lead to the following
situations:
• emotional lability;
• depression;
• euphoria.
Behavioural changes
Damage to the frontal lobe can lead to the following
behaviour issues:
• agitated states;
• disinhibition;
• reduced motivation.
Perceptual disturbances
Perception is the process of acquiring, interpreting, select-
ing and organising sensory information. Damage to areas
within the brain that co-ordinate sensory and motor infor-
mation can lead to the following:
• figure–ground differentiation;
• spatial awareness;
• inattention or neglect;
• disturbances in constructional abilities.
Apraxia is a disorder of planning. The individual has the
ability to perform a movement or talk about what the task
will involve but is unable to perform the task in the correct
sequence.
Cognitive, emotional, behavioural and perceptual im­­
pairments will all affect the success of an intervention. An
individual’s ability to concentrate, remember, understand
and be motivated will determine the effectiveness of a
treatment. It is important that these impairments are
assessed by the multi-disciplinary team (MDT) to ensure
that each healthcare profession can manage these aspects
within their treatments.
Auditory disturbances
Deafness directly related to neurological conditions is rela-
tively uncommon in neurological patients. When it occurs
it is usually a result of trauma to the structures of the audi-
tory system.
Communication disturbances/swallowing
Damage to Broca’s area within the brain and motor com-
ponents that produce muscle movement can lead to the
following:
• dysarthria – a difficulty in articulating words owing to
muscle weakness or lack of co-ordination producing
slurred speech;
582
• dysphasia (expressive and receptive) – the processing
part of speech is affected. Individuals can have
difficulty saying what they want (expressive) or
understanding what the word means (receptive).
Fatigue
A sense of overwhelming tiredness that is not fully under-
stood. This is a common feature for multiple sclerosis
patients, who struggle to perform functional activities
owing to fatigue and not physical weakness. Fatigue
should not be confused with poor endurance. Endurance
relates to an individual’s ability to maintain a period of
aerobic exercise. A person with poor endurance is likely to
have limited cardiovascular fitness rather than be fatigued.
Bladder/bowel incontinence
Incontinence can be a result of damage to the control
centres of the brain for bodily functions (see autonomic
disturbances) but also damage to motor pathways produc-
ing muscle control.
Autonomic disturbances
Autonomic dysfunctions may be a result of damage affect-
ing autonomic areas or pathways. Following spinal cord
injury, some patients can present with autonomic dysre-
flexia. This is a sympathetic nervous system discharge
producing hypertension, bradycardia, sweating, skin vaso-
constriction, headache, pilo-erection and capillary dila-
tion. This response is often triggered by impaired bladder
or bowel function, or other noxious stimulus.
ASSESSMENT OF NEUROLOGICAL
PATIENTS
As in all areas of physiotherapy, assessment is an ongoing
process that is an integral part of treatment. Assessment
of neurological patients is complex, and a particular diag-
nosis can result in very different presentations. Many
members of the healthcare team will carry out assess-
ments. Wherever possible, joint assessments with sharing
of information will be carried out. Often, the initial assess-
ment occurs over a number of sessions, because carrying
out a full assessment in one attempt can frequently be too
tiring for the patient. Gathering information over a longer
period of time invariably gives a much more accurate
picture of the patient’s strengths and difficulties.
Why do we do assessments?
• To identify the patient’s problems.
• To establish or define the patient’s level of
impairment and activity and participation
limitations.

• To establish baseline measurements of the patient’s
impairments, activity and participation limitations,
and goals.
• To inform treatment choices.
Assessments generally include a subjective assessment
(questioning) and an objective assessment (clinical exami-
nation). In addition, the use of standardised outcome
measures is recommended as a way of promoting evidence-
based practice and is part of good clinical practice.
Subjective assessment
Obtaining a thorough subjective history is very important.
This can come from a variety of sources: the medical notes,
nursing notes, the patient, relatives and carers. Initial inter-
views can be important, not just for gathering informa-
tion, but also because this is where establishing a rapport
with the patient and carers begins.
Physiotherapists need to draw on all aspects of their
communication skills to allow the patient and family to
be at ease. Increasingly, in appropriate cases, initial inter-
views take place in the patient’s home. This not only
ensures the person is more relaxed, but allows assessment
of the patient’s functional environment. Later, when home
programmes are being devised, knowledge of the patient’s
home can be invaluable.
When assessing patients with communication disorders,
it is important to find alternative or supplementary
methods of communicating with the patient. Collabora-
tion with the speech and language therapist is invaluable
at such times.
While interviewing the patient, important clues can be
observed with regard to physical abilities, communication,
cognition, emotion, hearing, vision and attention span. It
should also be noted how much the patient changes posi-
tion, attends to posture and so on. Assessment thus begins
the minute contact is made with the patient.
The assessment should include both background history
and also components specific to physiotherapy. Back-
ground history should include demographic details, past
medical history, diagnosis, history of present condition,
present condition, medication, social factors (housing,
family, lifestyle, care circumstances) and details of the
involvement of other healthcare professionals.
Objective assessment
The main purpose of the clinical examination is to gather
information about the patient’s movement disorder
and level of functional ability (Freeman 2002). Initially,
observe the patient and try to draw conclusions
about what they are able to do unaided. It is important
to remember that at no point must the patient be put at
risk. It is part of the physiotherapist’s role to ‘risk assess’
what is reasonable to allow the patient to attempt inde-
pendently and what they need help with in order to be
Neurological physiotherapy Chapter 26
safe. Objective assessment should include assessment of
active and passive range of movement and strength. This
will guide observation of posture and movement analysis
in sitting, lying to sitting, sit-to-stand, transferring from
bed to chair, standing and walking, etc. The exact activities
observed and/or assisted will depend on the level of ability
of the patient. Once the patient has been given the
opportunity to demonstrate what they can do unaided,
assistance can then be given to ascertain what the person
can achieve with help. This is where assessment and
treatment begin to merge into one and the same thing.
The assessment begins when initial contact is made. For
instance, observing the person’s gait when they walk
into the room often gives a more accurate picture of
functional gait pattern than when the person is asked to
walk while being watched.
International Classification of
Functioning, Disability and Health
The WHO provides a useful framework and common
terminology for describing and measuring the conse-
quences of disease and the impact that rehabilitation
may have on them (Edwards 2002). This is the Interna-
tional Classification of Functioning, Disability and Health,
known more commonly as ICF, which provides a standard
language and framework for the description of health
and health-related states. This describes changes in body
function and structure (impairment), what a person with
a health condition can do (their level of ability), as well
as what they actually do in their usual environment (their
level of participation).
• ‘Body function’ considers the loss or abnormality of
body structure, or of a physiological or psychological
function.
• ‘Activity’ refers to the nature and extent of
functioning at the level of the person. It may be
limited in nature, duration or quality. It considers
if a person can do a task and how well they do it.
• ‘Participation’ refers to the nature and extent of a
person’s involvement in life situations in relation to
impairment, activities, health conditions and
contextual factors.
Research by the Greater Manchester Outcome Measures
Project team identified the domains that physiotherapists
need to measure during clinical assessment in neurologi-
cal patients using the ICF as a framework. (Tyson et al.
2008). They suggested neurological assessments should
include assessment of:
Impairments (problems in body functions or
structures)
• ataxia/co-ordination
• balance impairment: postural sway
• oedema
• muscle tone/spasticity
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 Tidy’s physiotherapy
• pain
• personal fatigue
• posture impairment: alignment, weight distribution
• range of movement/contracture
• sensation and proprioception
• subluxation
• walking impairment: speed, endurance, step length,
cadence, etc.
• weakness
Activities (ability an individual has in executing
activities)
• balance activity – sitting, standing, dynamic,
supported, assisted
• mobility activity – bed mobility, sit-to-stand,
transfers, walking, stairs/steps, etc.
• upper limb activity – grips/grasps, dexterity, activities
of everyday life
• walking activity – in/outdoor, assistance, use of
equipment, independence.
Ultimately, physiotherapy aims to improve an individ-
ual’s ability to undertake activities to improve function,
participation and quality of life.
OUTCOME MEASURES
Objective measurement of function is core within rehabili-
tation, with both clinical guidelines and professional
bodies such as the Chartered Society of Physiotherapy
(CSP) explicitly stating that standardised outcome meas-
ures should be used. Therefore, part of the objective
assessment should include use of standardised outcome
measures, which provide baseline information on indi-
vidual’s ability and can be repeated to evaluate effective-
ness of treatment. In the current climate of limited
resources and financial cuts, it is vital that physiotherapists
undertake robust, standardised measures to enable evalu-
ation of the effectiveness of their treatment at an indi-
vidual and service level. It is no longer acceptable to state
physiotherapy treatment is effective – we need to be able
to provide evidence to justify this.
Measurement implies the quantification of data in
either absolute or relative terms. Determining the effec-
tiveness of an intervention by measuring its effect on an
outcome provides the basis for evidence-based healthcare
(Edwards 2002). Outcome measures take the guesswork
and subjectivity out of evaluation and can assist the physi-
otherapist in proving clinical effectiveness.
Outcome measures also provide a method of commu-
nication. The importance of a language of universal use
among clinicians must be promoted. The focus on multi-
disciplinary care and the blurring of traditional profes-
sional boundaries requires, at the very least, a system of
measurement that can be understood by and utilised by
the whole interdisciplinary team.
584
CSP core standards of physiotherapy practice
(2005) standard 6
Taking account of the patient’s problems, a published,
standardised, valid, reliable and responsive outcome
measure is used to evaluate change in the patient’s
health status.
The outcome measure should be:
• applicable to the clinical setting;
• relevant to the patient’s problems;
• related to the aims of treatment;
• standardised, valid, reliable and responsive measure;
• used to evaluate change against the aims of treatment.
Physiotherapists should:
• have the necessary skill and experience to administer
and interpret;
• ensure the instruction manual is followed to
administer and score.
There are a wide range of outcome measures available
and care is required when deciding which outcome
measure to use and when. The general principles to follow
when developing and/or considering the use of outcome
measures are:
• deciding what needs to be measured;
• selecting the appropriate outcome measure;
• does it measure what you want it to measure
(reliability, validity and sensitivity)?;
• ease of use on a day-to-day basis (clinical utility).
For a discussion of outcome measurement theory and
properties in rehabilitation, we refer the reader to Finch
et al. (2002).
CSP website
The CSP has provided a summary of the outcome
measures currently available, which have relevance to
physiotherapy care interventions. It can be found on the
CSP website at www.csp.org.uk.
Outcome measures should be sensitive enough to allow
for measurement of changes over time. The use of a suita-
ble outcome measure for all physiotherapy interventions
is an essential part of the treatment and management
process, and the clinical area of neurology is no exception.
Outcome measures in context
Physiotherapy outcome measures should be considered in
the wider context of rehabilitation. Rehabilitation can be
considered a problem-solving and educational process
aimed at reducing disability and enhancing function
in people who are affected by disease (Wade 1992). Reha-
bilitation principles are based upon the enhancement of
 Neurological physiotherapy Chapter 26

activity by restoring skills and capabilities through func-
tional retraining and environmental adaptation. Rehabili-
tation promotes independence and aims to facilitate the
fullest potential physically, psychologically, socially and
vocationally for a patient. Rehabilitation involves the
recovery or improvement of function, as well as preven-
tion of disability and the maintenance of a social role.
Irrespective of the approach taken towards reha­
bilitation, the ability to quantify the function is the key
to successful treatment. This process involves assessment,
treatment-planning, goal-setting and evaluation of out­
come. The WHO ICF classification and the process of
rehabilitation together provide the context for which
outcome measurement is used in physiotherapy.
Table 26.1 provides a summary of the outcome meas-
ures commonly used within neurology. It is not meant to
be comprehensive and the reader is directed to the ‘Further
reading’ list at the end of the chapter.

Table 26.1  Outcome measures frequently used within the clinical setting

Dimension Outcome measure References

Impairments

Muscle strength Hand-held dynanometer Bohannon et al. (1995)

Medical Research Council (MRC) grades MRC (1976)

Range of motion Goniometry Norkin and White (1975)

Tone Modified Ashworth Scale Bohannon and Smith (1987)

Sensation Nottingham Sensory Assessment Lincoln et al. (1998)

Fatigue Fatigue Severity Scale Petajan et al. (1996)

Activity

Global activity
Generic Barthel Index Mahoney and Barthel (1965)
Functional Independence Measure Granger et al. (1993)

Disease-specific Motor Assessment Scale for Stroke Carr et al. (1985)

Focal activity
Gait Ten-metre timed walking test Wade (1992)
Rivermead Mobility Index Collen et al. (1991)

Mobility Rivermead Motor Assessment Lincoln and Leadbitter (1979)

Balance Brunel Balance Assessment Tyson & DeSouza (2004)

Berg Balance Scale Berg et al. (1989)
Functional Reach Test Duncan et al. (1990)
Timed get-up-and-go test Podsialo and Richardson (1991)

Upper-limb function Box and Block Test Mathiowetz et al. (1985)

Nine-hole Peg Test Mathiowetz et al. (1985)
Action Research Arm Test Crow et al. (1989)

Participation London Handicap Scale Harwood et al. (1997)

Environmental Status Scale Mellerup et al. (1981)

Quality of life
Generic Thirty-six-item Short Form Health Survey Ware et al. (1993)
Nottingham Health Profile Hunt et al. (1981)

Disease-specific Thirty-nine-item Parkinson’s Disease

Questionnaire Peto et al. (1995)
Functional Assessment of Multiple Sclerosis Cella et al. (1996)

585
 Tidy’s physiotherapy
Goal-setting
Definition
Goal-setting refers to the identification and agreement of
targets that the patient, therapist and team will work
towards over a specified period of time (Wade 1999a,
1999b).
Once the assessment is complete, key problems need to
be identified by using clinical reasoning processes. Goals
of treatment, with appropriate timescales, can be formu-
lated with the patient and the family. Goals need to be
negotiated and discussed with all parties, including the
rehabilitation team, so that there is a clear understanding
of what is involved in achieving them. Failure to go
through this process can lead to frustration and misunder-
standing for all parties, particularly the patient and the
family.
The planning of goals is necessary to ensure that the
rehabilitation effort is as effective and efficient as possible
(Elsworth et al. 1999). Outcome is better if the goals
involve the patient, are challenging and are set at different
levels.
The evidence relating to goal-setting is limited, but there
is a general trend towards the inclusion of goal-setting in
the rehabilitation process (Wade 1999c). With the empha-
sis on patient-centred care and inclusion of the patient in
the decision-making processes, a formal process of goal
planning will help to improve the co-ordination and
co-operation of all those people involved. Co-operative
goal setting makes the process of rehabilitation more
patient-focussed and helps to motivate the patient through
the long period of rehabilitation and beyond. In other
words the effects of treatment will be long-lasting and
continue to be evident when treatment has ceased.
Good rehabilitation practice should involve SMART
goals (specific, measurable, achievable, realistic,
time-framed).
1. Set meaningful and challenging but achievable goals.
2. Involve the patient and carers.
3. Include short- and long-term goals.
4. Set goals both at a team and an individual
professional level.
It is common practice to set goals for the long, medium
and short term. In summary, the terms commonly used to
document goals are:
• long-term goals = aims;
• medium-term goals = objectives;
• short-term goals = targets.
Wade (1999a) defines these terms as given in Table 26.2.
In summary, goal-setting allows for the alignment of
patient and professional goals. It is a method of ensuring
586
Table 26.2  Aims, objectives and targets
Describes a state
Aim Is for the patient and family
Is in terms of a social role or
functioning or well-being
Objective Is set within the medium term
Involves direction of change as
much as achieving a specific
state
Is framed in terms of patient
behaviour and environment
Target Is set within the short term
Is specific and often involves only
one named person/profession
May be set at any level or in terms
of the rehabilitation process
Adapted from Wade (1999b).
that the rehabilitation team focusses on the needs of an
individual patient and can help to motivate patients. It
should lead to an overall improvement in treatment effec-
tiveness and provide a method of measuring the effective-
ness of treatment interventions (McGrath and Adams
1999; Edwards 2002).
List of problems and goals
Now the assessment is complete, a problem and goals
list needs to be formulated. It is important to bring the
problems identified as a physiotherapist together with the
patient’s/carer’s perceived problems. Problems and goals
need to be agreed with the patient and family. At the
end of the day it is important to remember that the
goals should be the patient’s, not the physiotherapist’s
(Table 26.3).
INTERVENTIONS
Task-specific practice
Ultimately, the majority of treatment aims to increase
ability at a task or activity, and, consequently, one approach
to treatment is simply to practise the task itself. Task-
specific practice – repeated practice of tasks similar to
those commonly performed in daily life – is a component
of current approaches to stroke rehabilitation. In the past
the focus of treatment was on reducing impairments in the
expectation that activities would naturally improve.
Systematic reviews of treatment interventions suggest
that participants benefit from exercise programmes in

Table 26.3  Problems and goals
Problem list Reason for Agreed goals (in
(with date set in problems order of priority)
order of priority)
which functional tasks are directly trained, with less
benefit if the intervention is impairment-focussed (Van
Peppen 2004). Examples of task-specific practice include
practising sit-to-stand, walking and reaching activities,
and are often mixed with other components, including
strengthening and treadmill training.
How the intervention might work
Many aspects of rehabilitation involve repetition of move-
ment. Repeated motor practice has been hypothesised to
reduce muscle weakness and spasticity (Feys 1998, Nuyens
2002), and to form the physiological basis of motor
learning (Butefisch 1995), while sensorimotor coupling
contributes to the adaptation and recovery of neuronal
pathways (Bruce and Dobkin 2004). Active cognitive
involvement, functional relevance and knowledge of per-
formance are hypothesised to enhance learning (Carr and
Shepherd 1987).
Evidence
Most research has been undertaken on patients with
stroke. A Cochrane review, acknowledged as the best
single source of evidence about the effects of healthcare
interventions, has been undertaken on repetitive task
training for improving functional ability after stroke
(French et al. 2007). This showed repetitive task training
resulted in modest improvement in lower limb function,
but not upper limb function. Training may be sufficient to
impact on daily living function. However, there is no evi-
dence that improvements are sustained once training has
ended. An evidence-based review of upper limb interven-
tions found repetitive task-specific training may improve
arm function (EBRSR 2009).
UK stroke guidelines
Emerging evidence suggests that giving the patients the
opportunity to practise functional activities (task-specific
training) may be important in improving outcomes. The
UK clinical guidelines (Intercollegiate Stroke Working
Party 2008) for stroke state:
Task-specific training should be used to improve
activities of daily living and mobility:
• Standing up and sitting down
• Gait speed and gait endurance
Neurological physiotherapy Chapter 26
Review date Treatment plan Date goal achieved,
signature and job title. If not
achieved state reason why
Exercise
Exercise (as covered in Chapter 13) includes stretching,
strengthening and aerobic types of activities. If performed
regularly with enough repetitions and appropriate dura-
tion these activities can develop into an exercise pro-
gramme that will improve an individual’s range of
movement, muscle strength and physical fitness.
Current literature reviewing the effectiveness of these
types of exercise now shows that strengthening exercises
are beneficial to many types of neurological patients in the
acute, rehabilitation and community settings (Weiss et al.
2000; Romberg et al. 2004). A Cochrane review suggested
that aerobic exercise to develop physical fitness in stroke
patients can improve their walking speed, tolerance and
level of mobility (Saunders et al. 2009).
Any activity that seeks to enhance or maintain a
function or movement can be classed as exercise. Task-
specific training is one such form of exercise that has been
proven to improve function in neurological rehabilitation
(see above).
In summary, exercise should be considered a key part of
the rehabilitation programme in the acute, rehabilitation
and community settings. The exact number of repetitions,
intensity, how often and content are currently being
looked into. The reader should review the emerging
evidence base to identify what will work best.
Treadmill training
The recovery of walking is important to function. It influ-
ences the discharge destination and package of commu-
nity support an individual receives when leaving a
rehabilitation environment. Physiotherapists concentrate
a large amount of time on regaining safe mobility, be it
independent or with an assistive device. The importance
of repetitive practice (as highlighted by task-specific train-
ing and strengthening) has forced therapists to look at
alternative methods for achieving increased intensity and
duration of walking practice.
The use of walking aids allows body weight to be sup-
ported but leads to an altered gait pattern, which can be
tiring to maintain. Hoisting equipment allows a patient’s
body weight to be partially supported while walking and
a more normal gait pattern to be adopted. However, a large
space is required to walk a patient with this type of equip-
ment so intensity, distance and duration are low. The
introduction of a treadmill, which provides a constant flat
moving surface, gives patients the chance to walk greater
distances without moving around a room and provides
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 Tidy’s physiotherapy
Figure 26.2  Treadmill.
safety with the use of a partial body weight support
(PBWS). This type of walking practice can reduce
the number of therapists needed to walk a patient
(Figure 26.2).
A recent review by Ada et al. (2010) shows that
mechanically-assisted walking with body weight support
systems is more effective than overground methods of gait
rehabilitation and does not have any detrimental effects
on an individual’s walking speed or capacity. Again, the
reader is advised to look at the current published literature
available for treadmill training.
Novel interventions
Within the current health and economic climate, provid-
ing adequate rehabilitation services is becoming increas-
ingly challenging (RCP 2004). Arguably, as a result of
this, there has been a growing recognition that different
approaches, such as constraint-induced movement therapy
(CiMT), are needed to complement, or sometimes replace,
existing approaches.
Constraint-induced movement therapy
CiMT is an approach proposed by Edward Taub in the
1980s as a means of treating the upper limb following
588
a stroke. This form of therapy involves restricting the use
of the unaffected limb (often by wearing a glove) while
targeting the affected limb with intensive (up to six
hours per day), task-orientated, functional retraining
(shaping). This combined approach appears to prevent
the learned non-use phenomenon so often seen in stroke
patients by using a restraint on the unaffected hand com-
bined with an intensive practice schedule designed to
facilitate neuroplastic changes in the CNS. Over the last
few years this approach has been gaining in popularity
and in 2008 a high-quality randomised controlled trial
of over 200 patients (Wolf et  al. 2008, on the EXCITE
trial) demonstrated that the patients who received CiMT
achieved substantial improvements in the functional use
of their affected arm and quality of life, even two years
after treatment had stopped. In spite of the promising
results from these studies, there remains a problem with
adoption of this approach into mainstream clinical
practice.
In addition to this there has been a growing recognition
that technology could play a significant role in the
rehabilitation programmes of the future. Virtual reality,
robotics and functional electrical stimulation (FES) are
three emerging rehabilitation interventions that have
been incorporated into rehabilitation programmes.
Virtual reality
Virtual reality (VR) is a computer-based, interactive,
multi-sensory simulation environment. The main types
of VR are immersive and non-immersive. In immersive
VR systems, the user feels as though they are actually
present in the computer-generated world. Non-immersive
VR systems still require the user to interact with the
environment but provide a lesser feeling of ‘presence’
within the virtual world. Supporters of VR feel that it
provides a safe environment for users to learn or relearn
skills that can be fun and help to motivate the user
(Rizzo and Kim 2005). VR systems fulfil many of the
requirements for sensory-motor relearning by being flex-
ible enough to allow the task to be tailored to meet
the needs of the client and afford the achievement of a
variety of rehabilitation goals (Page 2003). In addition
to this, another vital component for sensory-motor re­­
learning is provided, namely feedback on performance of
the task to both the client and the therapist (Adamovich
et al. 2009).
An extensive review of English-language scientific litera-
ture was carried out by Henderson et al. (2007) on the use
of immersive and non-immersive VR in rehabilitation of
the upper limb post-stroke in acute, sub-acute and chronic
stroke, adult patients. The review concluded that the
current evidence on the effectiveness of VR in the rehabili-
tation of upper limb in clients post-stroke is limited but
sufficiently encouraging to justify further research in this
area (Figure 26.3).

Figure 26.3  Repositioning of objects in an immersive virtual
environment (CAVE). Reproduced with permission of the Centre
for Virtual Environments, University of Salford, UK.
Robotics
Robotic devices have been developed to try to offer an
alternative intervention for treatment of upper limb post-
stroke, especially for patients with little, or no, use in their
affected arm. One of the main drivers for robotics has been
the need to deliver a large number of repetitive move-
ments in order to facilitate recovery. Rehabilitation in the
early stages of stroke requires a high percentage of thera-
pist’s time and is labour intensive. Two examples of these
robotic devices are MIT-MANUS (or the In-Motion system)
and GENTLE, which are single point of contact robotic
designs. More recently, a dual point of contact robotic
system, iPAM, has been developed to more closely mimic
the manner in which a therapist handles the upper limb
(Jackson et al. 2007). There is some evidence to suggest
that robotic-aided therapy could be more effective than
conventional therapy (Prange et al. 2006); however, once
again, in spite of these promising findings, the uptake of
robotic therapy remains in its infancy owing to the high
cost of equipment and its lack of usability in the home
environment (Figure 26.4).
Functional electrical stimulation (FES)
One intervention that is showing significant promise for
the restoration of function is FES. FES is ‘the use of Neu-
romuscular Electrical Stimulation to activate paralysed
muscles in a precise sequence and magnitude so as to
directly accomplish functional tasks’ (Sheffler and Chae
2007). The most established application for FES is in
the treatment of ‘drop foot’ post-stroke. In 2009, the
National Institute for Health and Clinical Excellence
(NICE) concluded that the evidence base for FES in drop
foot was adequate to support its use. The NICE Specialist
Advisers reported that the key efficacy outcomes of FES
included improved gait, reduction in effort when walking,
Neurological physiotherapy Chapter 26
Figure 26.4  iPAM: A physiotherapist instructing the patient
on how to use the stroke rehabilitation robotic system for
arm exercises. Reproduced with permission of iPAM team, Leeds
University, UK.
reduction in pain and discomfort, reduction in falls, return
to work and other quality of life outcomes. FES stimulates
the common peroneal nerve via surface stimulation or
implantable electrodes. In turn, this creates muscle activa-
tion of the anterior tibial and peronei muscles resulting in
a lifting of the foot to achieve toe clearance and aiding
more consistent foot placement on the ground. A small
but growing number of patients elect to have electrodes
implanted into the epineurium of the peroneal nerve as
an alternative to using surface stimulation. In both
methods, the electrodes are linked to a stimulator unit
either by leads or by using wireless technology. A pressure
sensor switch under the foot determines when stimulation
occurs (Figure 26.5).
The use of FES for the upper limb is also gathering a
more convincing evidence base. Recent studies by Popovic
et al. (2005) and by the Salisbury group (Mann et al.
2005) suggest that it is possible to achieve clinically sig-
nificant results if the FES treatment is based on the volun-
tary initiation of functional movements.
Unsurprisingly, approaches that challenge more long
standing treatment approaches, such as the Bobath
Concept, will take time to become embedded in the minds
and hearts of practitioners. It is important to stress that
these novel interventions need to be seen as an adjunct to
the therapeutic process rather than one that replaces it.
Both patients and practitioners need to be persuaded that
the evidence base for their implementation is strong and
that it provides an additional dimension to the ‘toolbox’
of practitioners. These interventions show the potential to
free up valuable therapist time and provide a situation
where patients can access rehabilitation interventions in
order to practise functional movements at their own pace.
589
 Tidy’s physiotherapy

Patients have expressed the view that they wish to be able

to access rehabilitation without the presence of a therapist
(McNair et al. 2005). Such opportunities enhance rather
than undermine practitioner approaches and should be
viewed as an opportunity rather than as a threat.

NEUROLOGICAL CONDITIONS

Stroke
The word stroke is used to refer to a clinical syndrome of
presumed vascular origin typified by rapidly developing
signs of focal or global disturbance of cerebral functions
lasting more than 24 hours or leading to death. Stroke is
the third most common cause of mortality and the leading
cause of long-term disability worldwide (Mackay and
Mensah 2004), with over 900,000 people living in England
A who have had a stroke (DH 2005). It affects between 174
and 216 people per 100,000 population in the UK each
Common peroneal nerve year (Mant et al. 2004), and accounts for 11% of all deaths
dividing into deep and in England and Wales. The risk of recurrent stroke within
superficial branches five years of a first stroke is between 30% and 43% (Mant
Skin et al. 2004).
The conditions are traditionally referred to as stroke,
transient ischaemic attack and subarachnoid haemor-
rhage, and are briefly described below.
Transient ischaemic attack (TIA) is a clinical syndrome
A
characterised by an acute loss of focal cerebral or ocular
B function with symptoms lasting less than 24 hours. It is
thought to be a result of inadequate cerebral or ocular
blood supply as a result of low blood flow, thrombosis or
embolism associated with diseases of the blood vessels,
F E D heart or blood (Hankey and Warlow 1994). Transient
ischaemic attacks affect 35 people per 100,000 of the pop-
ulation each year and are associated with a very high risk
of stroke in the first month of the event and up to one year
afterwards (Rothwell et al. 2007). Some people have a
mild residual deficit, which persists for days or weeks. The
National Clinical Guidelines for Stroke (Intercollegiate
C Stroke Working Party 2008) state that it is important for
people who suffer a TIA to commence a daily dose of
300 mg aspirin immediately. This helps to reduce the risk
B
of a further TIA or stroke.
Figure 26.5  (a) Functional electrical stimulation (FES) device Subarachnoid haemorrhage (SAH) is a haemorrhage from
to assist with foot clearance; (b) diagram showing nerve a cerebral blood vessel, aneurysm or vascular malforma-
distribution; (A) control unit, (B) strap, (C) foot switch under tion into the subarachnoid space, i.e. the space surround-
heel, (D) electrode, (E) electrical current, (F) cell body (motor ing the brain where blood vessels lie between the arachnoid
neuron). Reproduced with permission of the National Clinical FES and pial layers. SAH affects 6–12 people in each 100,000
Centre, Salisbury, UK. of the population per year and constitutes about 6% of
incident first strokes. Clinically, the acute presentation is
usually different from the presentation of other strokes,
specifically because it presents with sudden onset of severe
headache and non-focal neurological symptoms, which
may include loss of consciousness.

590

Risk factors
Strokes can occur at any age but are more common in
the elderly. There are several risk factors associated with
cerebrovascular disease (see Table 26.4).
A stroke has a major impact on a person’s life. It can
lead to long-term restriction in functional activities and
necessitate long-term care. Patients who have suffered a
stroke (cerebrovascular accident) present healthcare pro-
fessionals with a variety of complex physical, psychologi-
cal and social problems. The sudden loss of any capacity
causes severe stress not only to the patient but also to the
family. The resultant neurological deficit can have a dev-
astating outcome.
The signs and symptoms associated with a stroke are
dependent upon the size and location of the lesion. A
stroke usually results in hemiplegia (paralysis of one side
of the body). This hemiplegia is contralateral (opposite)
to the side of the brain in which the lesion occurs. An
interruption of blood flow to the brain leaves the patient
with a focal loss of function of varying severity. The most
common deficit is a motor deficit. Other neurological defi-
cits can include:
• visual;
• perceptual;
• sensory;
• communication;
• swallowing.
Pathology
Strokes are non-progressive in nature and are caused by
ischaemia or haemorrhage. A small number of strokes are
caused by congenital abnormalities of the blood vessels
and can result in spontaneous intercranial haemorrhage.
Table 26.4  Risk factors for stroke
Major risk factors Minor risk factors
Hypertension Contraceptive pill
Raised cholesterol Excessive alcohol consumption
Atherosclerosis Physical inactivity
Diabetes mellitus Obesity
Cardiac disease
Smoking
Adapted from Weiner and Goetz (1994).
Neurological physiotherapy Chapter 26
These defects of the blood vessels are known as arte­
riovenous malformations (AVMs). They are liable to sub-
sequent bleeding and surgical intervention is the treatment
of choice (Stokes 1998; Fawcus 2000).
Ischaemic stroke
Ischaemic stroke occurs when an embolus (a migrating
clot) or thrombus (a fixed clot) lodges itself in a blood
vessel, obstructing the blood flow to the area distal to the
blockage. This causes an abrupt interruption to blood flow
and leads rapidly to cell death and focal neurological
deficit. The thrombus is usually a result of atherosclerosis
and is often associated with hypertension, diabetes mel-
litus, and coronary or peripheral vascular disease. The
symptoms of ischaemia develop over a few minutes.
The area affected by the stroke will depend upon the
distribution of the artery and the degree of anastomosis
by other cerebral arteries. The addition of oedema at the
site of the lesion will add to the focal deficit. Once the
oedema has reduced the residual deficit will become
apparent.
Haemorrhagic stroke
A haemorrhagic stroke occurs when there is a rupture of a
blood vessel into the brain tissue. This can occur as a result
of hypertension that causes lipohyalinosis to occur in the
small arteries of the brain causing micro-aneurysms to
form, which then rupture. The onset is dramatic, with
severe headache, vomiting and loss of consciousness.
Subarachnoid haemorrhage
This occurs when there is bleeding into the subarachnoid
space following the rupture of a berry aneurysm near the
circle of Willis. There is a sudden intense headache associ-
ated with vomiting and neck stiffness. Loss of conscious-
ness may occur. Ten per cent of people will die within a
few hours and 40% within two weeks (Stokes 1998). Sur-
gical intervention is the best hope of recovery, followed by
intensive rehabilitation.
Clinical features
The clinical manifestations of occlusion of the cerebral
arteries are shown in Table 26.5.
Further reading
The range and severity of clinical features is extremely
varied. The recommended reading at the end of the
chapter provides readers with texts that deal with these
signs more comprehensively.
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 Tidy’s physiotherapy

Table 26.5  Arteries involved in cerebral vascular Medical management

occlusion Any person who arrives at hospital with an acute onset
neurological syndrome with persisting symptoms and
Artery Clinical manifestation   signs (i.e. potential stroke) needs full diagnosis to separate
of occlusion out acute cerebrovascular causes from other causes. It is
important to establish the type of stroke that has occurred
Middle cerebral artery Dense contralateral hemiplegia because the medical management will depend on whether
(supplies most of Contralateral homonymous it is an ischaemic, haemorrhagic or a subarachnoid stroke.
the convexity of hemianopia The National Clinical Guidelines for Stroke (Intercollegi-
the cerebral Cortical type of sensory loss ate Stroke Working Party 2008) outlines the recommended
hemispheres) Speech problems in left treatments and management.
hemisphere lesions, with The diagnosis of stroke is primarily dependent upon the
neglect of contralateral side clinical presentation and confirmed by a brain scan. It is
Lesions in the right hemisphere important to diagnose as quickly as possible so immediate
result in parietal damage, actions can be taken to reverse, or at least limit, brain
visuospatial disturbances damage. The National Stroke Strategy states: ‘Patients
and left-sided neglect requiring urgent brain imaging are scanned in the next
Posterior cerebral artery Visual disturbance scan slot within usual working hours, and within 60
Contralateral homonymous minutes of request out-of-hours with skilled radiological
field defect and clinical interpretation being available 24 hours a day.’
Memory disturbance and Ten to 15% of patients following stroke are suitable for
contralateral sensory loss thrombolysis treatment. Thrombolysis means the break-
ing up of blood clots. Thrombolysis or ‘clot-busting’ medi-
Anterior cerebral artery Contralateral monoplegia cine called tissue plasminogen activator (tPA) can dissolve
Cortical sensory loss the blood clot following acute ischaemic stroke and sig-
Sometimes behavioural nificantly improves outcome.
abnormalities associated
Other medical management usually consists of the
with frontal lobe damage
treatment of any underlying pathology (e.g. hypertension)
Adapted from Stokes (1998). and the prevention of secondary complications.
In the UK there are recommendations for the type of
service provision stroke sufferers can expect. Research sug-
The clinical features depend on the size and severity of gests that stroke patients do better when treated in a
the lesion. Many of the clinical features of damage to the specialised stroke unit that has a co-ordinated multi-
CNS can be manifested (see clinical features section). Gen- disciplinary stroke team (Fawcus 2000; Edwards 2002).
erally, there will be a mixture of these features. The list is
not exhaustive and it is beyond the scope of this text to Physiotherapy management
cover every possibility. No two patients are alike.
The physiotherapy-specific national guidelines for stroke
(RCP and CSP 2008) contain the recommendations from
Management the National Clinical Guidelines that have direct impli­
cations for physiotherapists and aim to provide ready
Time access to the latest guidance. They should be viewed as a
The nature of the problems faced changes over time. framework to guide clinical decisions rather than as rigid
The National Clinical Guidelines (Intercollegiate Stroke rules. The guidelines are continually updated in the light
Working Party 2008) consider: of new evidence. Examples of the guidance are given in
• prevention; Boxes 26.1 and 26.2.
• acute phase (0–7 days), usually dominated by
medical diagnosis and treatments; Multiple sclerosis
• sub-acute or recovery phase (1–26 weeks), usually
dominated by rehabilitation; Introduction
• long-term (over six months), usually dominated by Multiple (disseminated) sclerosis is a progressively degen-
support and care. erative disease of the CNS of unknown cause, whose path-
There are three stages of management: medical manage- ological trademarks are inflammation and demyelination.
ment, rehabilitation and prevention (Fawcus 2000). The The presenting clinical features can be very varied, result-
general increase in chronic disease has led to an increased ing in a complex combination of physical, psychological
importance of health promotion strategies. and cognitive problems. This highly variable presentation

592

Box 26.1  Rehabilitation treatment approach
All members of a stroke service should:
• use an agreed consistent approach for each problem
faced by a patient, ensuring the patient is given the
same advice and taught the same technique to
ameliorate or overcome it;
• give as much opportunity as possible for a patient to
practise repeatedly and in different settings any tasks
or activities that are affected;
• work within their own knowledge, skills, competence
and limits in handling patients, and using equipment,
being taught safe and appropriate ways to move and
handle specific patients if necessary.
Box 26.2  Rehabilitation treatment quantity
(intensity of therapy)
• Patients should undergo as much therapy appropriate
to their needs as they are willing and able to tolerate.
In the early stages they should receive a minimum of
45 minutes daily of any therapy that is required.
• The team should promote the practice of skills
gained in therapy into the patient’s daily routine in a
consistent manner and patients should be enabled
and encouraged to practise that activity as much as
possible.
• Therapy assistants may facilitate practice but should
work under the guidance of a qualified therapist.
(and often unpredictable condition) poses a major chal-
lenge to therapists if they are to assist individuals in man-
aging the condition as effectively as possible.
The prevalence of multiple sclerosis varies worldwide,
with the lowest among populations living nearest to the
equator. The condition appears to be most common in
temperate climates. People who emigrate before the age of
15 years exhibit the rate of incidence of their adopted
country (Dean and Kurtzke 1971). These facts seem to
suggest that there may be an environmental trigger that
allows the disease to develop through a genetic or immu-
nological susceptibility in children below the age of about
15 years that is no longer present in adults.
Approximately 15% of individuals with multiple scler-
ois have an affected relative. This risk rises to 1 : 50 for
offspring and 1 : 20 for siblings of affected persons
(Sadovnick et al. 1988).
Another possible contributing factor to the onset of
multiple sclerosis could be gender. Multiple sclerosis is
more common in women than men, with a ratio of
approximately 2 : 1. Race appears to have an influence,
with black and Asian populations having a lower inci-
dence. Other suggested factors are diet and socioeconomic
status, with the higher the standard of living the higher
the risk of developing multiple sclerosis.
Neurological physiotherapy Chapter 26
Key point
In the UK, an estimated 80,000 people have been
diagnosed with multiple sclerosis. This makes it the
second highest cause of neurological disability in young
adults. Approximately 1 per 800–1000 of the population
is affected, with the average onset of the condition being
at 30 years of age (Sadovnick and Ebers 1993). The range
of onset is extremely broad, from 10 years to 59 years.
Pathology
Acute stage
Breach of the blood-brain barrier is one of the first signifi-
cant events to occur at this stage. T-lymphocytes, in par-
ticular, are targeted against the vascular wall. They are
responsible for the secretion of cytokines, which then
recruit other cells including macrophages. The lymphocyte
makes a hole in the endothelium and enters the CNS. This
results in a perivascular inflammatory lesion that leads to
tissue damage, particularly of myelin.
This inflammatory stage can vary in its duration from
days to a month. The intensity and duration of the attack
will determine the overall extent of the damage. This phase
is associated with vasogenic oedema that ultimately
resolves over a matter of weeks, with repair of the blood-
brain barrier. A residual fibrous scar is then left on the
myelin sheath, termed a plaque or sclerosis.
Later stages
In the early stages of the condition, demyelination is not
the main cause of any symptoms but rather the inflamma-
tion itself. However, as the condition progresses, repeated
onset of the attacks results in more permanent damage.
Over a period of time the CNS combats this damage by a
number of compensatory mechanisms, but eventually the
amount it can compensate for the deficits is superseded
by the structural damage. Permanent deficits are the final
outcome of this run of events.
Forms of multiple sclerosis and diagnosis
About 45% of sufferers initially present with a relapsing–
remitting form of the condition (RRMS). An acute flare-up,
lasting from a few days to a few weeks, is followed by a
period of remission where no symptoms are displayed.
The periods of relapse and remission can vary in them-
selves, with an acute relapse being followed by a period of
remission lasting weeks to months.
About 40% of the people who initially presented with
RRMS will go on to develop a secondary stage of progres-
sion with or without superimposed relapses – known as
secondary progressive multiple sclerosis (SPMS). The person
appears to exhibit a steady deterioration, without any
noticeable acute periods to account for this.
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 Tidy’s physiotherapy
The third main form of the condition, known as primary
progressive multiple sclerosis (PPMS), presents as a steadily
deteriorating condition from the onset, with no identifi-
able relapses or remissions. The rate of deterioration can
be fairly rapid in some cases. About 10–15% of cases are
in this category.
Two further categories need to be included for com-
pleteness: benign (10–20% of cases), with no significant
disability owing to multiple sclerosis 10 years after onset,
and malignant (Marburg’s disease).
In spite of the increasing reliance on magnetic reso-
nance imaging (MRI) as a diagnostic tool, clinical evalua-
tion continues to be the main method of diagnosing
multiple sclerosis. Other investigations used are evoked
potentials and, less commonly, analysis of cerebrospinal
fluid by way of a lumbar puncture. The most widely used
diagnostic criteria are those of Poser et al. (1983).
Clinical features
Any part of the CNS may be affected, so, unsurprisingly,
symptoms vary tremendously according to which part of
the CNS is affected. Some of the most common clinical
features will be described here, but readers may need to
refer to other texts for more detailed information (see also
www.msif.org).
Vision
The optic nerve, cervical cord, brainstem and cerebellar
peduncles are most commonly affected. Frequently at onset
the first feature is of optic neuritis of varying severity. Pain
is felt behind the affected eye with some element of visual
disturbance occurring. In 58% of cases acuity is affected
without pain. However, overall more than 90% of cases
recover the majority of their visual acuity. Later on, other
symptoms affecting eye movement are dysmetria, nystag-
mus, internuclear ophthalmoplegia (slowing of adduc-
tion) and occular flutter. Diplopia might be experienced.
Sensation
Sensory symptoms are common early on in the course of
the condition. Numbness, pins and needles, tightness
around a limb and other more unusual sensations, such
as of water running down a limb, are the most frequently
experienced. Later on, joint proprioception is also com-
monly affected.
Motor function
Motor symptoms are more common than sensory symp-
toms and are usually more disabling in the long run.
Changes in muscle tone, weakness, tremor, poor co-­
ordination and ataxia are all impairments that often
result in difficulties with movement. Neurological condi-
tions where the white matter is affected often result in
considerable spasticity. Spasticity, most commonly in the
legs, may be present with or without accompanying weak-
ness. Other than cerebellar ataxia, spasticity is frequently
594
the most disabling feature in people with multiple sclero-
sis. Individuals may report spasms, sometimes at night,
which can be painful. Cerebellar ataxia can result in arm
movements being un-coordinated (intention tremor), a
wide-based gait pattern and speech disturbances. The
reader is asked to refer to the ‘Clinical features’ section for
more specific details on each of the above symptoms.
Swallowing
Individuals entering the later stages of multiple sclerosis
may experience swallowing difficulties (dysphagia). An
under-estimation of the degree of swallowing difficulties
may result in bronchopneumonia and can ultimately,
therefore, be potentially life-threatening. Swallowing is a
highly complex motor skill that requires careful assess-
ment by a speech and language therapist, dietician and
radiographer. Videofluoroscopy using a modified barium
swallow is an essential investigation if comprehensive
assessment of dysphagia is to occur. Assessment of the
individual’s posture during swallowing should not be
overlooked. Ultimately, if severe difficulties persist with
oral feeding then other alternatives, such as a gastrostomy,
may need to be considered.
Bladder and bowel
Bladder disturbances in multiple sclerosis are very
common and often take the form of either detrusor hyper-
reflexia or detruso-sphincter dyssernygia. Urgency, fre-
quency, nocturnal disturbances and urge incontinence are
the various types of bladder presentations. People often
report that social trips have to be strategically planned
around where the nearest toilet might be. The former type
of bladder disturbance rarely occurs without the presence
of spasticity in the legs. The second type of bladder distur-
bance (detruso-sphincter dyssernygia) presents as delay or
inability to void, frequency, urgency and an inability to
fully empty the bladder. This may result in urinary reten-
tion and the susceptibility to urinary tract infections.
Treatment is often successful in the form of muscle
relaxants, anticholinergic drugs and self-catheterisation.
Constipation is the main bowel problem and is rela-
tively straightforward to treat.
Key point
One of the most common and usually most disabling
symptoms is that of fatigue. Fatigue in its truest sense,
for people with multiple sclerosis, is usually described as
‘a deterioration in performance with continuing effort’
(Barnes 2000).
Pain and fatigue
People with multiple sclerosis tend to be more susceptible
to pain syndromes such as trigeminal neuralgia,

myelopathies and musculoskeletal-type pain. The latter is
usually as a result of poor posture and poor alignment of
joints – sometimes through soft tissue adaptations and
over stressed joints.
As the day progresses, any activities involving physical
effort are often increasingly difficult to carry out. Fatigue
is a significant feature of most people with multiple scle-
rosis. This is an important consideration when it comes to
planning physiotherapy treatment interventions.
Cognition
Cognitive difficulties, such as disturbances in functional
memory, reduced information processing speeds and
im­­paired intellectual function, are more common in
people with multiple sclerosis than is widely recognised.
Cognitive impairments in multiple sclerosis may contrib-
ute significantly to any reduction in functional capability.
Although these types of impairments are more common
in people with longstanding multiple sclerosis, they have
also been shown to exist at a time when there are relatively
few physical symptoms (Van den Burg et al. 1987).
Management
Medical management
Key point
Medical management can be divided into interventions
that may influence the condition directly and those that
help to manage the symptoms.
In acute relapses, rest and steroid therapy are the mainstay
of medical management. In spite of the widespread use
of steroids in multiple sclerosis there remains little con-
sensus in the UK over the most appropriate dose and
mode of administration. Steroid therapy is most com-
monly administered in the form of 1 g intravenous meth-
ylprednisolone for 3–5 days with or without a reducing
dose of steroids. The most common oral regimen is
prednisolone 60 mg daily, reducing to 0 over 1–3 weeks.
Low-dose oral steroids are generally better tolerated, but
evidence of efficacy is less robust.
Steroids have been shown to shorten the recovery time
during relapses, although they do not seem to have an
overall effect on the long-term progress of the condition.
Longer-term use of steroids is less well supported in the lit-
erature and any potential benefits must be weighed against
the potentially harmful side effects of steroid therapy.
Interferone β has now unequivocally been proven to be
of benefit to some people with multiple sclerosis by reduc-
ing the number of relapses that occur in RRMS, thereby
delaying progression of the condition.
Many other types of medical intervention are utilised to
manage the consequences of the disease process, such as
Neurological physiotherapy Chapter 26
antispasmodic medication to reduce the effects of spastic-
ity and referral for further investigations depending upon
the presenting symptoms. For example, an ultrasound scan
of the bladder may be needed to establish incomplete
voiding of the bladder.
Physiotherapy management
The key to any successful intervention is a comprehensive
and ongoing assessment of the person’s difficulties and
needs. A co-ordinated interdisciplinary approach is also
crucial if the condition is to be managed effectively (Ko
Ko 1999). Rehabilitation programmes must be tailored to
meet the needs of the individual and carers, who should
be at the centre of the goal-setting approach.
Individuals with multiple sclerosis often feel their needs
are best served by services that allow direct access to them
at the time of need. They also often feel they benefit most
from a consistent approach on an ongoing basis that
allows continuity of management rather than episodes of
care (Robinson et al. 1996).
The main aims of any physiotherapy intervention must
be to keep the individual as functionally independent as
possible. In order to do this, often in the face of potential
increasing loss of function, it is vitally important that the
physiotherapist works with the person on a psychological,
as well as a physical, level. Timing of interventions is
crucial and is one of the main reasons for the need for
ongoing monitoring of this group of patients. The impor-
tance of early contact with patients cannot be over stated.
This allows time for an effective rapport to be established
which will become invaluable as the disease progresses.
Even in the early stages, the more aware the patient is of
their condition, the more effective the management is
likely to be. Physiotherapists need to be proactive in the
area of patient education by consulting with the evidence
base in conjunction with an informed knowledge of the
condition, to ensure this component of the management
programme is as effective as possible. Establishing and
encouraging early self-management with the patient will
pay dividends in the long run.
Additional goals of a physiotherapy programme are to
minimise abnormalities of muscle tone, preserve the integ-
rity of the musculoskeletal system by preventing secondary
problems (Thompson 1998), improve posture and give
advice on postural management, and to facilitate the
use of efficient functional movement patterns, including
re-education of gait.
Motor neurone disease
Introduction
Motor neurone disease (MND) is characterised by progres-
sive degeneration of motor neurones:
• anterior horn cells in the spinal cord, resulting in
lower motor neurone lesions (LMN);
595
 Tidy’s physiotherapy
• corticospinal tract cells, resulting in upper motor
neurone lesions (UMN);
• motor nuclei in the brain stem, resulting in both
upper and lower motor lesions.
Key point
‘Motor neurone disease’ is, in fact, a global term mainly
used in the UK and Australia. In other parts of the world
the condition is often referred to as ‘amyotrophic lateral
sclerosis’ (ALS).
Although MND is primarily a disease of the motor neu-
rones, there may be occasional involvement of other areas
of the CNS. The autonomic nervous system, sensory
nerves, lower sacral segments of the spinal cord and the
three cranial nerves that control movement of the eyes are
usually unaffected.
The aetiology of the condition is unknown, although
5% of people have a familial form (Figlewicz and Rouleau
1994). It is a condition that usually affects people in later
life, starting at between 50 and 70 years, with a marginally
higher occurrence in males. The cause and pathogenesis
of the motor neurone degeneration in ALS appears to be
a complex and multifactorial process. More recently it has
been hypothesised that altered RNA processing may be
involved in the disease pathogenesis (Van Damme and
Robberecht 2009).
Key point
Precise figures for incidence and prevalence are not
known. The incidence is thought to be 2 per 100,000
per year, while the prevalence is estimated to be 7
people per 100,000 of the population. The approximate
number of people with MND in the UK is 5000 (MND
Association 2000).
Clinical features and diagnosis
The onset of MND is usually insidious and the exact pres-
entation depends upon the areas of the CNS affected.
Where there is lower motor neurone degeneration, the
main features are weakness, muscle wasting and fascicula-
tion of the nerves undergoing degeneration. Degeneration
of upper motor neurones usually results in spasticity with
accompanying weakness and muscle wasting.
Forms of MND
The following is a broad categorisation of the forms of
MND, but, in reality, there is often considerable overlap
between the forms.
596
Amyotrophic lateral sclerosis (ALS)
This is the most common form of the condition (65%). It
is more common in males and involves both upper and
lower motor neurones. It is characterised by spasticity,
muscle weakness, hyperactive reflexes, with possible
bulbar signs of dysarthria, dysphagia and emotional labil-
ity. The hands tend to be affected initially with the person
reporting clumsiness, with evidence of thenar eminence
wasting and the shoulder also often being affected early
on. With bulbar involvement, speech, swallowing and the
tongue are affected. The average survival rate is 2–5 years.
Progressive bulbar palsy
This affects 25% of people with MND, with slightly older
people and women being more commonly affected. Both
upper and lower neurones may be involved. Dysphagia
and dysarthria are characteristic of this form of the condi-
tion owing to lower motor neurone damage causing nasal
speech, regurgitation of fluids via the nose, tongue atrophy,
pharyngeal weakness and fasciculation. Life expectancy is
usually between six months and three years.
Progressive muscular atrophy
This affects approximately 7.5% of people with MND
when there is predominantly lower motor neurone
involvement. Males are more affected than females at a
ratio of muscle wasting and weakness, with weight loss
and fasciculation the main presenting features. Mental
deterioration and dementia are found in fewer than 5%
of people (Tandan 1994). Life expectancy is usually more
than five years.
Primary lateral sclerosis
This is a rare form of the condition that affects mainly the
upper motor neurones. It is characterised by spastic quad-
raperisis, pseudobulbar symptoms, spastic dysarthria and
hyperreflexia. A survival rate of 20 years or more can be
expected.
Diagnosis
As with many other progressive diseases, no one specific
test exists for the diagnosis of MND. Investigations often
include imaging (MRI), myelogram (electromyography),
blood tests and clinical investigations to exclude the pos-
sibility of other conditions such as syringomyelia or cervi-
cal spondylosis (Swash and Schwartz 1995).
Management
Medical management
Medical and healthcare professionals have a significant
role to play in the management of this condition owing to
its complex and potentially rapidly deteriorating course.
Owing to the high number of professionals involved in
the person’s care, it is vitally important that interventions

be co-ordinated in some way. As in many cases where a
high number of professionals from various agencies are
involved, individuals with MND and their families often
report that one of the most frustrating aspects of their
management is the lack of co-ordination of service provi-
sion. In spite of the logic for a MDT approach to the man-
agement of people with MND, a recent Cochrane review
(Ng et al. 2009) concluded that the evidence for multi-
disciplinary care in the treatment of people with MND was
poor owing to there being an absence of randomised con-
trolled trials. It was highlighted that further research is
needed into the most appropriate study designs, outcome
measures, care-givers’ needs and evaluation of optimal set-
tings for treatment together with more research into the
type, intensity and cost-effectiveness of interventions.
The family and their long-term needs must be con­
sidered. It is vitally important that the person with
MND maintains as much control over his/ her life as pos-
sible. Timely interventions, speedy responses, advice and
support, ongoing assessment and access to equipment and
services are the main needs for this group of people.
Rilutek
In 1996 a drug called Rilutek, whose active ingredient is
riluzole, became the first licensed drug treatment
available for people with MND. It is not a cure for the
condition but has been reported to extend life by several
months (NICE 2001).
Physiotherapy management
Assessment of the person’s needs on an ongoing basis is
taken as a prerequisite before any treatment interventions.
Again, a MDT assessment and approach is necessary for
this group of people.
In the early stages, information on MND and support
agencies, advice on appropriate exercise programmes,
support for the person with MND and the family, and
providing a point of contact will be the main physiother-
apy interventions.
As the condition progresses – and this will vary from
person to person – physiotherapy interventions will take
the form of advice on exercise programmes and how best
to incorporate these into everyday activities. This will
ensure that the movement is as functional as possible.
Active-assisted exercises may be required if the person
needs assistance to move. The main aim at this stage is to
keep the person as independent as possible for as long as
possible. To this end, assistive devices may be needed and,
again, the physiotherapist may need to liaise with the
occupational therapist, orthotist and rehabilitation engi-
neers in the case of environmental control systems.
As movement becomes more difficult through weakness
or spasticity, passive movements are indicated to prevent
Neurological physiotherapy Chapter 26
secondary impairments of the musculoskeletal system. It
is vital that carers be involved in this process, if they so
wish, to assist in the process of maintenance. A large part
of the physiotherapist’s role will be teaching and advising
carers and other members of the team. One aspect of
advice from the physiotherapist might be how to move
and position the client in the most appropriate manner.
The client is likely to be increasingly reliant on other forms
of mobility during this stage of the condition and, as such,
will need advice on the type of wheelchair (often powered)
required.
Non-invasive ventilation to aid breathing has been pur-
ported to increase the survival rate and increase, or at least
maintain, the quality of life of people with MND. However,
the evidence base is still fairly limited with only two ran-
domised controlled trials having been carried out to date
(Radunovic et al. 2009). This finding was based on indi-
viduals with better bulbar function.
With individuals with dysphagia it is important that the
physiotherapist works closely with the speech and lan-
guage therapist and nursing staff to ensure optimum posi-
tioning for a safe swallow. Monitoring of respiratory
function will also be necessary for this group of clients.
Terminal stage
In the terminal stage of the disease the person may be
cared for at home or admitted to a hospice. The main aims
of treatment are management of any prevailing symptoms,
ensuring the person is as comfortable as possible, provid-
ing psychosocial support, advising on potentially life-
prolonging treatments and end-of-life care. It is of vital
importance that both practical and emotional support is
forthcoming for the family and carers. Deterioration is
often rapid, with the most common cause of death being
respiratory tract infection leading to respiratory failure.
Brain injury
Introduction
Brain injury and head injury tend to be used interchange-
ably within the literature. An acquired brain injury (ABI)
refers to any brain injury caused by the following:
• trauma;
• vascular accident;
• cerebral anoxia, e.g. as a result of cardiac arrest;
• toxic or metabolic conditions, e.g. hypoglycaemia;
• infection, e.g. meningitis.
The brain injury may be direct as a result of physical
injury to the brain or indirect if a situation arises
where cerebral perfusion pressure reaches a critical low
and regulatory mechanisms are lost leading to ischaemic
damage (Mendlow et al. 1983). Alternatively, intracranial
causes can be the result of damage, such as acute trau-
matic haematomas, raised intracranial pressure (ICP)
and infection.
597
 Tidy’s physiotherapy
Table 26.6  Classification of brain injury
Classification Score on Glasgow
Coma Scale (GCS)
Mild 13–15
Moderate 9–12
Severe 3–8
Traumatic brain injury (TBI) describes a head injury
resulting from a traumatic event. TBI is a subset of ABI
with the other subset being non-traumatic events. In addi-
tion to the damage which leads to the TBI there are often
associated injuries, such as limb fractures and internal
organ damage. Skull fractures may be simple or com-
pound, undisplaced or depressed.
Any brain injury can be classified according to the
Glasgow Coma Scale (GCS) duration of coma, by the
length of post-traumatic amnesia (PTA) or by results
from a computerised tomography (CT) scan (Table 26.6)
(Department of Veterans Affairs 2008). PTA is defined
as ‘the length of time between injury and the restora-
tion of continuous day-to-day memory’ (Russell and
Smith 1961).
Key point
• Each year an estimated 1 million people attend
hospital A&E in the UK following head injury. Many
more head injuries go unreported and are not
assessed by medical professionals.
• Of these, around 135,000 people are admitted to
hospital each year as a consequence of brain injury.
• It is estimated that across the UK there are around
500,000 people (aged 16–74) living with long term
disabilities as a result of TBI. The DH document
National Service Framework for Long Term Conditions
(2005) provides some guidance on how to manage
these people.
• Approximately 85% of traumatic brain injuries are
classified as minor, 10% as moderate and 5% as severe.
• Men are two to three times more likely to have a TBI
than women. This increases to five times more likely
in the 15–29 age range.
• Road traffic accidents and sporting injuries are the
other most common cause of TBI, but alcohol
consumption and recreational drug use may be
contributing factors.
Adapted from Headway, The Brain Injury Association (Key feacts
and statistics: Traumatic brain injury); www.headway.org.uk.
598
Duration of coma Length of post-traumatic amnesia
<20 min <1 hour
<6 hours 1–24 hours
>6 hours >24 hours
Pathology
The most common causes of TBI are direct blows to the
head, deceleration and rotational forces. Contrecoup lesions
can occur as a result of falls or direct blows to the head
where there may be contusions at the site of impact along
with contusions at the opposite side to the impact. Often,
the frontal lobes are most prone to damage owing to their
proximity to the orbital ridges. Vascular damage usually
occurs from subarachnoid bleeding with intracerebral and
subdural haematomas appearing at the time of injury.
Potential problems following TBI
Post-traumatic epilepsy
This can be present in up to 40% of cases, depending on
the severity of brain injury. ‘Anticonvulsants may be
prescribed during the first 7 days following TBI for the
prevention of early seizures’ (RCP and BSRM 2003: 33).
Medication more commonly prescribed includes car-
bamazepine and valproic acid owing to their reduced
side effects in comparison with phenobarbital and pheny-
toin. Many anticonvulsants can produce significant side
effects.
Post-traumatic hydrocephalus
This refers to enlargement of the ventricular system and
generally is non-obstructive. If hydrocephalus is diag-
nosed, ventricular shunting is the usual treatment.
Neuroendocrine and autonomic disorders
These types of problem include hypertension,
hypothalamic–pituitary disorders and hyperthermia.
Hypertension can occur as a new condition in 10–15%
of patients but is usually transient and can be managed
effectively with beta-blockers.
Cranial neuropathies
These are a common occurrence following TBI, with
cranial nerves I and III and, less commonly, IV, VI and VIII
being affected.
Gastrointestinal and nutritional needs
Nutritional needs in the acute stages of TBI are reported
to increase by an estimated 25%. Long-term outcomes

have been more favourable owing to the nutritional needs
of patients being met (Young et al. 1987). Alternative
methods of feeding may need to be considered in the early
stages to achieve this aim. Problems with dysphagia occur
in approximately 25% of patients and this might also be
another reason why alternative methods of feeding may
need to be adopted.
Orthopaedic and musculoskeletal complications
Fractures are a common feature in TBI, with occult frac-
tures (where there is no evidence of fracture on initial
X-ray) being amongst the most serious problems. Periph-
eral nerve injuries are frequently under-diagnosed and
heterotopic ossification occurs in 76% of cases.
Continence
Urinary incontinence following TBI is very common
for a number of reasons but is primarily a result of
disinhibition.
Sexual dysfunction
The most common occurrence is oligomenorrhea, i.e.
infrequent or light menstruation. Other complications
include impotence, altered libido along with difficulties
created by any behavioural changes.
Motor function
Disturbances in the CNS can lead to hypertonicity, con-
tractures and disordered movement. Hypertonicity can
predispose patients to adaptive muscle shortening
(contractures). Timely and effective management of
hypertonicity can ultimately avoid the need for surgical
intervention. Movement disorders encountered might be
rigidity, tremors, ataxia, akathisia (feeling of inner restless-
ness and the patient feels unable to sit still) and dystonias,
including chorea.
Sensation
Disturbances in sensory function can present in the form
of diminished or absent cutaneous sensation (paraesthesia/
anaesthesia), or various agnosias such as sensory neglect.
Certain sensory disturbances can be addressed to some
extent within the rehabilitation programme. However,
long-standing sensory disturbances tend to persist.
Cognition and behavioural impairments
Altered cognition can be the most troublesome aspect of
a patient’s rehabilitation and long-term social reintegra-
tion. Commonly occurring features include disturbances
in level of arousal, speed of processing of information,
memory, abstract reasoning and flexibility, self-awareness,
distractability and limited attention span. Behavioural
deficits and psychosocial adjustment after TBI include
depression, poor social awareness, agitation, aggressive
Neurological physiotherapy Chapter 26
behaviour and difficulties in initiating activities (Wood
1990; Prigatano 1992).
Management
Medical management
The NICE Clinical Guidelines CG56 published in Septem-
ber 2007 provide information on triage, assessment, inves-
tigation and early management of head injury in infants,
children and adults. Assessment by a trained healthcare
professional in determining the nature and severity of the
head injury must be done. A CT scan, skull X-ray and
continual GCS monitoring all need to be carried out. In
some cases, intracranial monitoring will be necessary to
ensure no further damage or deterioration in the patient’s
condition occurs. Certain patients will require neurosurgi-
cal intervention, which cannot be covered in any detail
within this text (reference to Black and Rossitch (1995) is
suggested for further information). Additionally, any other
injuries, such as fractures, contusions and haematomas,
should be dealt with.
In summary, the overall goals in the acute setting are:
• gaining medical stability;
• clearing of post-traumatic amnesia;
• reduction of behavioural and physical dependence.
If the patient does not require a high level of medical
input, a less medically acute setting with intensive therapy
services may be more appropriate.
Physiotherapy management
Early stages
Within the intensive care environment the role of the
physiotherapist is to maintain respiratory function (see
Chapter 7) and reduce soft tissue complications owing to
prolonged bed positioning. All interventions during this
stage need to be carefully balanced against the risk of
raising the intracranial pressure (Ada et al. 1990).
As with many complex neurological conditions, patients
are best managed by an experienced interdisciplinary reha-
bilitation team using a patient-centred, goal-orientated
approach. Patients should be in an environment that is
conducive to intensive rehabilitation. It is increasingly
common for patients with complex disabilities to be
managed using a key worker or case manager approach in
order to provide continuity of the services delivered more
effectively.
Patients can present with a wide variety of impairments,
depending on the site of the damage. Patients with severe
physical impairments early on in their rehabilitation
will benefit from intensive rehabilitation (Hellweg and
Johannes 2008). However, by far an over-riding residual
problem is one of cognitive impairment, including disrup-
tion of executive functions. These types of impairments
and the resultant psychosocial implications can lead to
significant limitations in social interactions and can be the
599
 Tidy’s physiotherapy

main barriers to individuals returning to independent
living (Oddy et al. 1978; Oddy and Humphrey 1980;
Brooks and McKinlay 1983; Lezak 1986).
The effectiveness of physiotherapy rehabilitation is
currently under review (Teasell et al. 2007; Hellweg and
Johannes 2008; Holmberg and Lindmark 2008). It is now
recognised that intensive early rehabilitation leads to
better functional outcomes but the exact nature of these
interventions is unspecified. Only task-specific rehabilita-
tion shows strong evidence for improving outcomes and
is recommended from the literature. Most of the research
surrounding the rehabilitation of ABI and TBI consists of
single case studies and low-powered randomised control-
led trials. Even though these studies show some success of
individual interventions, the lack of quality means that
more research is needed to clearly identify what physio-
therapy interventions work best.
Later stage – after months or years
The cognitive abilities and behavioural presentation of
individuals with TBI will have an impact upon their level
of function. It is vital, therefore, that these elements
be assessed and taken into account when agreeing goals
for interventions. Historically, physiotherapists have failed
to take sufficient account of these factors, and subsequent
physiotherapy interventions have, perhaps, been less effec-
tive than they might have been. Access to a neuropsycholo-
gist or cognitive occupational therapist, who can assess
and advise on the most effective way to deal with these
factors when planning treatment, is invaluable.

Glossary

Agnosia Loss of knowledge or Dysphagia Difficulty in swallowing Hypotonicity Decreased muscle

inability to perceive objects
Anaesthesia Absence of sensation
Ataxia Loss of co-ordination
affecting functional movement
Babinski sign Abnormal response of
the plantar reflex (great toe turns
upwards on testing)
Bradykinesia Slowness of
movement
Clonus Succession of intermittent
muscular relaxation and
contraction usually resulting from
a sustained stretch
Diplopia Double vision
Dysarthria In-coordination of speech
Dysphasia Disruption of expressive
(produce) and/or receptive
(understand) speech
Dyspraxia Inability to execute
volitional purposeful movements
Dystonia Involuntary movement
characterised by twisting and
repetitive movement
Flaccidity Absence of muscle tone
Hemianopea Loss of visual field in
one half of each eye
Hemiplegia Paralysis of one side of
the body
Hypertonicity Increased muscle
tone
tone
Nystagmus Involuntary rhythmic
oscillation of one or both eyes
Paraesthesia Disruption of
sensation causing abnormal
sensation
Ptosis Drooped eyelid
Rigidity Stiffness of neurological
origin, increased resistance to
stretch throughout the range
Tone The active resistance of muscle
to stretch
Tremor Fine type of involuntary
movement (several types seen in
neurological dysfunction)

ACKNOWLEDGEMENTS

The authors would like to acknowledge Professor Bippin Bhakta and Sophie Makower (Charterhouse Rehabilitation
Technologies Laboratory, University of Leeds), Paul Taylor (National Clinical FES Centre, Salisbury), Irina Sanders, and
Professor David Roberts (Centre for Virtual Environment, University of Salford) for kindly providing photographs for
the rehabilitation technology section in this chapter.

FURTHER READING

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 Chapter
Physiotherapy in women’s health
Gill Brook, Tamsin Brooks, Yvonne Coldron, Ruth Hawkes, Judith Lee, Melanie Lewis,
Jacquelyne Todd, Kathleen Vits and Liz Whitney
INTRODUCTION
This chapter offers an overview of the role of the physio­
therapist in women’s health. Some of the expert con­
tributors are members of the Association of Chartered
Physiotherapists in Women’s Health (ACPWH), a profes­
sional network group of the Chartered Society of Phy­
siotherapy (CSP). Originally known as the Obstetric
Physiotherapists Association, it was formed in 1948 and
is one of the oldest such organisations.
Weblink
Association of Chartered Physiotherapists in Women’s
Health (ACPWH): http://acpwh.csp.org.uk/
The ACPWH forms a representative body that can be
consulted, and will act in the professional interest of phys­
iotherapists working in women’s health and in the specific
field of continence (including men). It encourages and
provides means by which physiotherapists may improve
specialist therapeutic skills and understanding of the
speciality; it also publishes a journal and hosts an annual
conference. In order to nurture interest in this field among
student physiotherapists there is a student award, which
provides funding to attend the annual conference.
There is a lack of evidence for some aspects of women’s
health physiotherapy and, to encourage research, support
may be offered in the form of a small bursary. There is, in
addition, a research officer who works closely with the
CSP and other relevant funding bodies to set the future
agenda for research and the ACPWH produces a compre­
hensive selection of leaflets for the public and health
professionals.
27 
The women’s health physiotherapist is a vital member
of the multiprofessional team and ACPWH maintains
strong ties with the Royal College of Midwives, the Asso­
ciation for Continence Advice and the Bladder and Bowel
Foundation. It communicates with other organisations
with a similar interest (e.g. the charities Wellbeing of
Women and the National Childbirth Trust).
Since 1999, the ACPWH has been a member of the
International Organization of Physical Therapists in
Women’s Health (IOPTWH), an official subgroup of the
World Confederation for Physical Therapy (WCPT) whose
mission is to improve healthcare for women internation­
ally through facilitation and promotion of best practice
women’s health physical therapy. In 2012, its membership
was 23 countries.
Weblink
International Organization of Physical Therapists in
Women’s Health (IOPTWH): www.ioptwh.org
ANATOMY AND PHYSIOLOGY
A physiotherapist needs knowledge of the pelvic anatomy
and the physiological changes relevant to women’s health.
Bones and joints of the pelvis
The pelvic girdle protects and supports the pelvic contents,
provides muscle attachment and facilitates the transfer of
weight from trunk to legs in standing, and to the ischial
tuberosities in sitting. The joints (Figure 27.1) are sup­
ported by some of the strongest ligaments in the body,
which may become more lax in pregnancy leading to
605
 Tidy’s physiotherapy

increased joint mobility and less efficient load transfer Muscles

through the pelvis.
The pelvic outlet at the base of the pelvis is narrower in Four pairs of abdominal muscles combine to form the
transverse diameter when compared with the pelvic inlet; anterior and lateral abdominal wall, and may be termed
it comprises the pubic arch, ischial spines, sacrotuberous the abdominal corset. Transversus abdominis (TrA),
ligaments and coccyx (Haslam 2004a). whose fibres run transversely, lies deep to the internal
abdominal oblique (IO) and external abdominal
oblique (EO), with the rectus abdominis (RA) central,
Sacroiliac
joint anterior and superficial (Figure 27.2). IO, EO and TrA
insert into an aponeurosis joining in the midline at the
Sacrum linea alba.
The deep abdominal muscles, together with the
Uterus pelvic floor muscles, multifidus and diaphragm, can be
considered as a complete unit and may be termed the
Fallopian lumbopelvic cylinder. This provides support for the
tube abdominal contents and maintains intra-abdominal pres­
sure (Cresswell et al. 1992). At low level muscle activity
Ovary
force is exerted on the thoracolumbar fascia and studies
suggest that this contributes to lumbopelvic stability,
crucial to pain-free resting posture and normal function
Symphysis (Richardson et al. 1999). Motor control of the muscles of
pubis the lumbopelvic cylinder is also significant in maintain­
ing continence and controlling respiration.
Figure 27.1  True and false pelvis: female reproductive Optimal function of these muscles depends on timing
organs. of recruitment, endurance, strength and co-ordination.

External
oblique
Rectus
Internal
abdominis
oblique
Transversus
Linea
abdominis
alba

Inguinal
ligament Conjoint
tendon
Inguinal
ligament
A B C

Figure 27.2  (a) Right rectus abdominis. (b) Right internal oblique and left external oblique muscles. (c) Left transversus
abdominis. (Reproduced from Palastanga et al. (2002) with permission.)

606
 Physiotherapy in women’s health
This can be adversely affected by pain, postural malalign­
ment, deficient nerve supply or fascial detachment.
The main function of RA is lumbar spine flexion
(Sapsford et al. 2001), while the obliques, interlaced diag­
onally in midline deep to the recti, produce side-flexion
and rotation of the spine.
Co-ordinated action of the abdominal muscles increases
intra-abdominal pressure which facilitates expulsive
actions – defaecation, micturition and parturition when
the pelvic floor is relaxed – and coughing, sneezing or
vomiting if the diaphragm is relaxed.
In later pregnancy, the growing uterus stretches the
abdominal muscles and may cause RA to be separated
in midline by several finger widths (Sapsford et al. 1998).
This inter-recti distance – diastasis rectus abdominis
muscle (DRAM) – can persist postnatally (Barton 2004;
Coldron et al. 2008).
The pelvic floor is a fascial and muscular sheet forming
the inferior boundary of the abdominopelvic cavity
(Figure 27.3). It supports the pelvic and abdominal con­
tents and comprises four layers. The deepest (viscerofas­
cial) is important for both organ support and muscle
attachment. The next part of the supportive mechanism
and assisting with the sphincteric control of the bladder
and bowel is formed by the levator ani muscles – pubococ­
cygeus (pubovisceral muscle), puborectalis, ileococcygeus
and ischiococcygeus. The co-coordinated action of levator
ani, in the presence of intact fascia, generates a rise in
intra-abdominal pressure to maintain organ support, and
urinary and faecal continence. Contraction of the pelvic
floor muscles (PFM) results in a cranio-ventral movement
that has been observed by real-time ultrasound (Lovegrove
Jones et al. 2009). The next layer is a dense triangular
membrane lying anteriorly – the perineal membrane.
It is of importance for connection of the urethra, vagina
and perineal body to the ischiopubic rami (De Lancey
2001). The most superficial external genital muscles
Ischiocavernosus
Bulbocavernosus
Transverse perineal
muscle
Levator ani
External anal
sphincter
Gluteus maximus
Figure 27.3  Pelvic floor muscles.
Chapter 27
– ischiocavernosus, bulbocavernosus and the transverse
perineal muscles – have a sexual function in assisting a
woman to achieve orgasm.
It has always been believed that the pudendal nerve,
from sacral nerve root S2–4, supplies all of the pelvic floor
muscles. However, Barber et al. (2002) suggested that
although the pudendal nerve supplies the urethral sphinc­
ter and the external genital muscles, levator ani has a
distinctive separate nerve supply from S3–5 which has
been named the ‘nerve to levator ani’. This theory is under
some dispute.
Pregnancy and childbirth are major contributory factors
to pelvic floor muscle dysfunction (Freeman 2002).
Women who suffer urinary incontinence in pregnancy are
twice as likely to be symptomatic 15 years after childbirth
(Dolan et al. 2003). Vaginal delivery also increases the
likelihood of future urinary and faecal disorders, but cae­
sarean section may not be fully protective (MacArthur
et al. 2006). It is also thought that there is a possible
genetic factor related to collagen (Hannestad et al. 2004).
Organs of reproduction
The uterus – a hollow, pear-shaped organ – comprises the
fundus, body, isthmus and cervix, and weighs about 50 g
in its normal state (Haslam 2004a). Together with the
ovaries, it is suspended in connective tissue and perito­
neum inside the true pelvis (Figure 27.1). The broad liga­
ment (a double fold of peritoneum) extends from the
lateral walls of the uterus to the sidewalls of the pelvis,
dividing the pelvic cavity into two compartments – the
anterior (containing the bladder) and the posterior (con­
taining the rectum). The ovaries lie in the broad ligament
on each side of the uterus. Behind and slightly above are
the trumpet-shaped open ends of the contractile fallopian
tubes. Their tentacle-like fringes (fimbriae) catch the ovum
when it erupts from the ovary at ovulation. The free ovum
is propelled along the fallopian tube to the uterus by a
peristaltic wave and the cilia lining the tube walls. On
fertilisation, the ovum is embedded in the endometrium
lining the uterus. If fertilisation has not occurred, the
lining is shed (menstruation).
The uterus has a remarkable capacity to grow as the fetus
develops during pregnancy, able to accommodate the baby
(in 1 litre of amniotic fluid within a membranous sac) and
placenta, which attaches to the uterine wall.
The physiology of pregnancy
Following fertilisation of the ovum, the first sign of
pregnancy is amenorrhea (cessation of menstruation). As
pregnancy progresses, the uterus grows, its muscle fibres
lengthening and thickening, and weight increasing from
50 g to 1000 g at term. By 12 weeks it has enlarged to
become an abdominal organ. Gestational dates can be
determined by the level of the uterus, which continues to
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 Tidy’s physiotherapy
rise until the later weeks of pregnancy. Co-ordinated con­
tractions of the uterus may be felt by women from about
20 weeks (Braxton Hicks contractions). These contractions
assist in blood flow through the placental site and in
development of the lower uterine segment. The cervix
gradually increases in size with an increase in collagen
content, hypertrophy of external muscle fibres and increase
in vascularity (McNabb 1997) and becomes slightly
softer in consistency. A mucous plug acts as a barrier to
infection.
The disc-shaped placenta grows during pregnancy with
the major responsibility of maintaining the fetal circula­
tion in order to facilitate blood gas exchange, nutrition
and excretion, and to be a barrier to noxious substances.
It also produces progestogens and oestrogens.
The fetus grows and develops within the amniotic sac
and is nurtured by the placenta via the umbilical cord.
Its heartbeat can be detected at about 10 weeks with
ultrasonic equipment and movements may be felt by
primigravidae (women pregnant for the first time) at
18–20 weeks, whereas multigravidae (women who have
experienced a previous pregnancy) may notice this at
16–18 weeks.
Pregnancy is governed and controlled by hormones,
which affect various systems. Some are of particular rele­
vance to the physiotherapist:
• progesterone decreases smooth muscle tone, initiates
sensitivity to carbon dioxide in the respiratory centre,
and causes an increase in maternal temperature,
breast development, and storage of fat deposits for
milk production;
• oestrogen influences uterine and breast growth and
development, prepares prime receptor sites (e.g.
pelvic joints) for relaxin, and causes increased water
retention. Increased vaginal glycogen predisposes
pregnant women to thrush;
• in target areas relaxin replaces collagen with a
modified form of greater pliability and extensibility.
It may have a softening effect on connective tissue
(pelvic floor and abdominal fascia), increasing
extensibility in those structures. It also inhibits
myometrial activity up to 28 weeks gestation.
On average, pregnancy lasts 40 weeks and is divided
into three trimesters, each of three months in duration.
Physiological and anatomical changes occur owing to hor­
monal changes and weight gain. These factors will influ­
ence the physiotherapy management of musculoskeletal
problems in pregnancy.
Within this text attention will be paid to the changes and
complications of most relevance to the physiotherapist
dealing with women during pregnancy and the postnatal
period. Further reading is advised (see the end of the
chapter).
608
MUSCULOSKELETAL CHANGES
DURING PREGNANCY
Postural changes
Kypho-lordotic, sway back and flat back have been
described as ideal postures (Kendall et al. 2005). The
overall equilibrium of the spine and pelvis alters as
pregnancy progresses but there is still confusion as to the
exact nature of any associated postural adaptation. With
weight gain, increased blood volume and ventral growth
of the fetus, the centre of gravity no longer falls over the
feet and women may need to lean backwards to gain
equilibrium (Abitol 1997) resulting in disorganisation of
spinal curves. Reported postures include a reduction in
lumbar lordosis (Moore et al. 1990), an increase in both
lumbar lordosis and thoracic kyphosis (Bullock-Saxton
1991) or a flattening of the thoracolumbar spinal curve
(Gilleard et al. 2002). These differences imply a large
individual variation with no ‘normal’ posture in preg­
nancy and antenatal lumbopelvic posture may be an
accentuation of normal pre-pregnancy posture. There will
be compensatory changes to posture in the thoracic
and cervical spines, and this combined with the extra
weight of the breasts may result in posterior displacement
of the shoulders and thoracic spine, and increase of
the cervical lordosis. Postural changes may still be present
12 weeks postnatally (Bullock-Saxton 1991).
Articular and connective  
tissue changes
Altered levels of relaxin, oestrogen and progesterone
during pregnancy result in an alteration to collagen
metabolism and increased connective tissue pliability and
extensibility. Therefore, ligamentous tissues are predis­
posed to laxity with resultant reduced passive joint
stability. The symphysis pubis and sacroiliac joints are
particularly affected to allow for birth of the baby. Liga­
mentous laxity may continue for six months postpartum
(Foti et al. 2000).
Biomechanical changes of the spinal and pelvic joints
may involve an increase in sacral promontory, an increase
in lumbosacral angle, a forward rotatory movement of the
innominate bones, and downward and forward rotation
of the symphysis pubis (Golightly 1982). The normal
pubic symphyseal gap of 4–5 mm shows an average
increase of 3 mm during pregnancy (Abramson et al.
1934). Pelvic joint loosening begins around 10 weeks,
with maximum loosening near term. Joints should return
to normal at 4–12 weeks postpartum (Snow and Neubert
1997). The sacrococcygeal joints also loosen. By the
last trimester, the hip abductors and extensors, and the
ankle plantarflexors increase their net power during gait
 Physiotherapy in women’s health
(Foti et al. 2000) and there is an increase in load on the
hip joints of 2.8 times the normal value when standing
and working in front of a worktop (Paul et al. 1996).
As the uterus rises in the abdomen the rib cage is forced
laterally and the diameter of the chest may increase by
10–15 cm (Polden and Mantle 1990).
Neuromuscular changes
Abdominal and pelvic muscles contribute to spinal and
pelvic stability via active tension exerted on the passive
ligamentous and fascial stability structures. During preg­
nancy the enlarged uterus results in elongation of
the abdominal muscles and separation of the linea alba
(Boissonnault and Blaschak 1988). Passive joint instabil­
ity (as seen in pregnancy) alters afferent input from joint
mechanoreceptors and probably affects motor neurone
recruitment. A decrease in muscle stiffness and thus active
stability of joints may result from alteration of muscle
spindle regulation (Bullock-Saxton 1999) and this is
applicable particularly to muscles around the pelvic girdle.
These changes may lead to poor recruitment of the muscles
responsible for pelvic girdle stability (particularly gluteus
medius and maximus) and result in decreased tension of
these muscles during walking, perhaps resulting in pelvic
girdle pain (PGP).
Rectus abdominis
As pregnancy progresses, rectus abdominis (RA) elongates
(Gilleard and Brown 1996) and becomes wider and
thinner (Coldron et al. 2008). In many women the dis­
proportion between width and thickness remains at 12
months postpartum (Coldron et al. 2008). Although the
consequences of this are unknown, the strength of gross
muscle flexion can be impaired at 24 weeks postpartum
(Potter et al. 1997b).
The linea alba becomes wider and thinner via
hormonally-mediated change as the fetus grows anteriorly,
with the two bellies of RA curving round the abdominal
wall (Haslam 2004b). In nulliparous women the inter-
recti distance (IRD) at the umbilicus is approximately
11 mm (± 3.62) whereas the divarication of the linea alba
during the third trimester and immediately postpartum
may vary widely between women, with an average gap of
42 mm (± 20.28) at the umbilicus (Coldron et al. 2008).
The linea alba can split and become a diastasis with
herniation of the abdominal contents. Diagnostic criteria
of a pathological diastasis at the umbilical level in people
under 45 years has been defined by Rath et al. (1996)
as an IRD of >27 mm. The IRD at the umbilical level
has been shown to resolve to about 22 mm (± 9.44)
by 8 weeks postpartum, when it reaches a plateau,
though in a minority of women a diastasis may persist
(Coldron et al. 2008).
Chapter 27
Lateral abdominal muscles
There is very little information on the effect of preg­
nancy on the three lateral abdominal muscles (transver­
sus abdominis (TrA), internal (IO) and external (EO)
obliques). However, research on normal subjects has
identified the importance of TrA as the prime stabiliser
of the trunk (Hodges 1999). Decreased stabilisation
of the pelvis happens in late pregnancy and poor stabil­
ity persists at eight weeks postpartum (Gilleard and
Brown 1996). In one study, EO appeared to atrophy
during pregnancy but hypertrophy in the postnatal
period to become thicker than that of nulliparous con­
trols (Coldron 2006). Furthermore, the thickness of the
middle fibres of IO and TrA was significantly greater in
day 1 postpartum women than that of controls, but by
eight weeks postpartum there was no difference between
the two groups. Parity, exercise and a history of lum­
bopelvic pain had no bearing on the results. The rele­
vance of these findings is unknown but it may be that
IO and TrA had an increase in stability function during
pregnancy from load-bearing with the weight of
the fetus.
Pelvic floor muscles
During pregnancy there is stretching to the pelvic floor and
trauma/tearing during labour and vaginal delivery. It is
now thought that the function and recruitment of TrA and
the pelvic floor musculature are closely associated, with
voluntary activity in the deep abdominal muscles resulting
in increased pelvic floor muscle activity (Sapsford and
Hodges 2001). There is an association between PFM
dysfunction and pregnancy-related lumbopelvic pain
(Pool-Goudzwaard et al. 2005).
LABOUR, BIRTH AND  
THE PUERPERIUM
Definition
Labour is defined as the process by which the products
of conception are expelled from the uterus after the 24th
week of pregnancy.
Labour
Labour can be described through a series of physiological
events which culminate in the delivery of the neonate
between 37 and 42 weeks of gestation. The specific trigger
initiating onset of labour remains unknown, although it
is understood that certain fetal and maternal hormonal
interactions and mechanical factors play a part. Increased
609
 Tidy’s physiotherapy

uterine contractility causes the taking up (effacement) of ischial spines’. When the presenting part distends the
the ripened cervix and subsequent opening (dilatation) in genital tract and pelvic floor a surge of oxytocin is released,
the primigravid (first pregnancy) woman. known as the fetal ejection or Ferguson reflex, whereby
strong expulsive contractions facilitate the birth. Through­
Stages of labour out the second stage women should be encouraged to
Labour continues to be described in three stages, though instinctively bear down as the urge occurs with a con­
this theory has been challenged in recent years (Winter traction, adopting positions which increase the pelvic
and Cameron 2006). outlet (Gupta et al. 2004). Prolonged breath-holding and
overzealous pushing should be avoided, as this interferes
First stage with placental perfusion and may compromise the fetus.
The environment should feel safe and non-threatening,
The first stage of labour is from the commencement of
with minimal intrusion from staff, and the midwife
regular uterine contractions effecting dilatation (opening)
should be confident in her skill to support normal labour
of the cervix, culminating when the cervix is fully dilated,
(Downe 2010).
allowing the passage of the fetus into the birth canal. It
can be further subdivided into the latent phase (early
labour), where contractions are short and irregular, and Observations
the active phase (established labour), where contractions
Maternal well-being and progress in labour is determined
become intense and regular (Chapman and Charles 2009).
by observation of the physiological and psychological
Contractions (tightening) and retraction (shortening) of
changes which occur in response to labour.
myometrial muscle fibres increase in length, strength and
frequency as labour progresses. The mucous plug (show)
is expelled as the cervix opens and the membrane sac Pain relief
(amnion and chorion) often spontaneously ruptures,
Kabeyama and Miyoshi (2001) demonstrated that self-
allowing amniotic fluid to drain.
control was the most important factor in a satisfactory
Various changes can be observed in women adapting
childbirth experience, and women who experienced
to the intensity of contractions. Expenditure of energy
labour as a challenge, utilising their own resources through
increases the need for hydration and food, although as
breathing and relaxation, had better outcomes. Manage­
labour progresses appetite is often suppressed. Women
ment of pain relief should therefore take a woman-centred
may appear hot, flushed and agitated as intense contrac­
approach utilising the whole spectrum of pain manage­
tions may cause pain, fear and distress. Endorphin release
ment options.
in response to pain provides an analgesic and euphoric
Non-pharmacological approaches to pain management, such
bolster, which may cause some women to appear calm,
as position and posture, play an important part in labour
quiet and withdrawn. Many women find relief through
and most women will naturally adopt positions which
their own instinctive behaviour, such as mobility, change
enhance labour, if they are provided the space and freedom
of position and posture (De Jonge and Lagro-Jansen
to do so. Warm baths, compresses, massage, breathing,
2004), warm baths or compresses, massage, relaxation and
relaxation, music, dance and distraction techniques can
distraction techniques.
also be used to great advantage in labour (Hamilton
As the cervix nears full dilatation further changes can be
2010). Complementary therapies, such as hypnotherapy,
observed in the woman as she enters the ‘transition’ into
aromatherapy, acupuncture and reflexology, should also
second stage. The intensity of contractions increases, exac­
be considered utilising suitably qualified practitioners.
erbating pain and stress, although the contractions may be
Transcutaneous electrical nerve stimulation (TENS) can be
less frequent. The woman is exhausted and often expresses
used in labour. A low-frequency high-intensity current of
defeat. She may appear agitated and overwhelmed by the
2–10 Hz is thought to increase the production of endor­
effort of labour, or conversely calm and removed. Increased
phins and encephalins. This is applied throughout labour
vocalisation, spontaneous shaking, rapid movement of the
and a high-frequency low-intensity current at 100–200 Hz
legs, nausea and vomiting may be seen, and she may
which activates the pain-gate mechanism (Melzack and
express an urge to bear down or push.
Wall 1982) is used during the more intense contractions.
The current is introduced via four electrodes placed over
Second stage the nerve roots to the uterus (T10–L2) and the pelvic floor
The second stage of labour is the expulsive stage culminat­ and perineum (S2–S4). The two channels enable indi­
ing in the birth. Commonly defined as commencing from vidual control of each pair of electrodes.
full dilatation of the cervix which was thought to herald TENS is easy to apply, is non-invasive and has no known
the urge to push, it has been suggested (Long 2006) that side effects for mother or baby. It allows mobility and
second stage labour commences ‘when the presenting affords the woman some control of her analgesia. It
part has passed through the cervix and is below the cannot be used in water and may, on occasion, interfere

610
 Physiotherapy in women’s health
with the cardiograph tracings. Recent evidence demon­
strates that a reduction in the demand for pethidine and
other pain relief was found when TENS was employed
(Poole 2007).
Inhaled analgesia as a premixed combination of 50%
oxygen and 50% nitrous oxide (Entonox) inhaled via a
mouthpiece is self-administered. Some women experience
a feeling of loss of control or drunkenness, nausea and
vomiting; however, the effects of Entonox wear off quickly
when inhalation is stopped.
Opiates, such as pethidine, diamorphine and meptazi­
nol, may be used to relieve pain in labour. Pethidine is
historically the most common drug of choice in the UK.
Easily administered by intramuscular injection these drugs
have similar pain-relieving properties, although their ben­
efits in labour have been challenged (Collis 2000) owing
to the episodic nature of contractions and the unpleasant
side effects of nausea, vomiting, drowsiness, amnesia,
feeling of loss of control and depression of the respiratory
centre, especially in the neonate. Neonatal drowsiness also
interferes with the establishment of breastfeeding.
Epidural will provide a pain-free labour provided it is
sited and working correctly. A regional anaesthetic is intro­
duced into the lumbar epidural space by an experienced
obstetric anaesthetist. A combination of local anaesthetic
(bupivicaine) and opioid (fentanyl) is used to provide
adequate analgesic effect with minimal impact on mobil­
ity and blood pressure. Continual infusion of drugs as
opposed to a bolus dose has been found to reduce the risk
of instrumental delivery (COMET 2001). Possible side
effects include dural puncture and possible headache, loss
of bladder sensation requiring catheterisation, risk of
instrumental delivery, infection, backache (possibly as a
result of poor posture or localised bruising), total spinal
block and respiratory arrest, neurological sequelae (rare).
Perineal trauma
During delivery the perineum stretches to accommodate
the fetus and can remain intact, or perineal trauma may
occur in the form of grazes and tears. Tears are classified
according to the extent of tissue damage – first degree tear
involves the skin of the fourchette and second degree also
includes the superficial perineal muscles. These tears are
usually repaired by the midwife. Third and fourth degree
tears involve the anal sphincter and rectal mucosa respec­
tively and require surgical intervention.
Episiotomy
Occasionally, an incision through the perineal tissues may
be required but should not be undertaken lightly and
always with consent. Two main indications for episiotomy
have been identified (Carroli and Belizan 2009): to enlarge
the vulval outlet in order to minimise severe trauma to the
vagina and perineum, in particular where instrumental
Chapter 27
delivery is required; and in cases of fetal distress to expe­
dite delivery. Local anaesthetic is infiltrated and a medi­
olateral incision is made to prevent damage to the
Bartholins gland and reduce the risk of extension of the
incision into the anal margin (Downe 2010).
Third stage of labour
The third stage is defined as the period from the birth of
the baby to complete expulsion of placenta and mem­
branes, and control of haemorrhage from the placental
site. It can be managed physiologically or actively with the
use of drugs. The placenta and membranes are examined
for completeness and occasionally part, or all, of the
placenta and/or membranes may be retained, requiring
anaesthetic and manual removal.
Caesarean section
Caesarean section is an operative procedure carried out
under regional or, more rarely, general anaesthesia.
Regional anaesthesia ensures that the woman can partici­
pate in the birth and recovers more quickly with less risk
of complications.
The fetus, placenta and membranes are delivered
through a transverse incision on the bikini line of the
abdominal wall and through the lower uterine segment.
On rare occasions a vertical or classical incision may be
performed; this is associated with increased morbidity.
Assisted birth
Assisted vaginal birth by vacuum extraction or forceps is a
widely practised intervention used to expedite delivery
where there is delay in the second stage, maternal exhaus­
tion or fetal distress. It is more commonly used among
women who choose epidural as a form of pain relief
(Anim-Somuah et al. 2005).
Vacuum extraction is the most common choice owing to
ease of use and increased safety. However, similar levels of
complications occur as with forceps delivery and vacuum
extraction is less efficient at achieving vaginal delivery. A
suction cup (Ventouse/Kiwi) is placed onto the fetal head,
and traction and maternal effort are applied during uterine
contraction in order to deliver the fetus.
Forceps delivery involves separately placing two spoon-
shaped metal blades (which lock into place) on either side
of the fetal head. Slow, steady traction and maternal effort
is applied to deliver the fetus. Forceps may also be used to
protect the head of the preterm fetus or the after coming
head in the breech (Hamilton 2010). Adequate analgesia
must be provided prior to assisted birth.
Induction
Induction of labour is an intervention to initiate labour
where there is disadvantage to the continuation of
611
 Tidy’s physiotherapy
pregnancy. The mother may also request induction for
social reasons (NICE 2008a). Indications for induction of
labour include prolonged pregnancy (exceeding 42 com­
pleted weeks), maternal factors (hypertension, diabetes),
or pre-labour rupture of membranes, which may lead to
infection risk. Fetal factors include growth restriction,
macrosomia (large baby), fetal anomaly or fetal death.
Different approaches to induction can be used individu­
ally or collectively:
• stretch and sweep – a digital vaginal examination to
stretch the cervix, sweeping the membranes and
separating them from the uterine wall;
• prostaglandin – administered vaginally to ripen the
cervix, which may initiate labour;
• artificial rupture of the membranes once the cervix has
started to dilate;
• intravenous oxytocin infusion may also be required.
Puerperium
Puerperium is defined as the six-week period following
childbirth during which the woman’s body returns almost
to its pre-pregnancy state:
• lactation is initiated and established or suppressed;
• the uterus involutes, returning almost to the
pre-pregnant size and position;
• the placental site begins to heal and the lochia (blood
loss) diminishes to a creamy white discharge;
• perineal trauma and abdominal wounds begin to heal.
Many women require a considerably longer time to
adjust both physiologically and psychologically to the
complex life-changing event of childbirth. High expecta­
tions with regard to regaining pre-pregnancy shape and
lifestyle are not always reflected in reality and can lead to
low self-esteem and feelings of inadequacy. Talking and
sharing worries both with the health professional and
other mothers can be beneficial, and women should be
made aware of local groups (Byrom et al. 2010).
PHYSIOTHERAPY IN THE
CHILDBEARING YEAR
Women’s health physiotherapists work as part of the
multi-disciplinary team (MDT) caring for pregnant
women. Contact with pregnant women may be in the
community, at a health centre, at a leisure centre or in the
physiotherapy department.
The role may include:
• education of pregnant women for pregnancy, labour
and beyond (see section on antenatal classes);
• advice on exercise (see the section on exercise and
pregnancy);
612
• identification, assessment and treatment of
musculoskeletal problems (dealt with in this
section).
Pelvic floor dysfunction
During pregnancy approximately one in three women
experiences stress urinary incontinence (Francis 1960;
Stanton et al. 1980; Viktrup and Lose 2001) and preg­
nancy and birth can have an adverse effect on the area
through perineal trauma, muscle, connective tissue and
pudendal nerve damage (Snooks et al. 1984; Allen et al.
1990). Pelvic floor muscle exercises (PFME) during preg­
nancy are effective in reducing urinary incontinence in
pregnancy and the immediate postnatal period (Mørkved
2007) and the National Institute for Health and Clinical
Excellence (NICE 2006) recommends PFME for every
woman during her first pregnancy (see the section on
urogenital dysfunction). During pregnancy, physiothera­
pists may consider it prudent to limit their intervention to
advice.
Pregnancy-related lumbar spine and
pelvic girdle pain
Lumbopelvic pain is common during pregnancy with a
prevalence described variously as ranging from 50% to
70% (Mantle et al. 1977; Fast et al. 1987; Berg et al. 1988;
Ostgaard and Andersson 1991; Wu et al. 2004; Mogren
and Pohjanen 2005; Gutke et al. 2006). It may be of spinal
and/or pelvic girdle origin (Ostgaard et al. 1996; Stuge
et al. 2003; Wu et al. 2004; Vleeming et al. 2004; Mogren
and Pohjanen 2005; Gutke et al. 2006). Pain of spinal
origin is normally referred to as low back pain (LBP).
Pregnancy-related PGP is a global term that encompasses
symphysis pubis dysfunction, diastasis symphysis pubis
and sacroiliac joint pain.
Lumbopelvic pain is often regarded as ‘a normal part of
pregnancy’ but, without appropriate treatment, a minor
episode may develop into a chronic problem. A third of
women report severe back pain that interferes with daily
life and compromises their ability to work (Ostgaard
and Andersson 1991; Mens et al. 1996). Most backache
resolves quickly postpartum, but may continue for 18
months (Ostgaard and Andersson 1992) or present post­
partum for the first time (Russell and Reynolds 1997).
Some patients experience a relapse around menstruation
and in a subsequent pregnancy (Mens et al. 1996).
The anatomical origins of pregnancy-related lumbopel­
vic pain vary and are difficult to determine and diagnose
(Nilsson-Wikmar et al. 1999). Common conditions
include unilateral sacroiliac dysfunction, symphysis pubis
dysfunction, minor lumbar disc herniation, lumbar zyga­
pophyseal joint problems, thoracic spine pain and coccy­
dinia. Women describe pain variously as occurring in the
 Physiotherapy in women’s health
low back, sacral, posterior thigh and leg, anterior thigh,
pubic, groin and hip areas. These may occur simultane­
ously or separately, antenatally, during delivery or postna­
tally (Heiberg and Aarseth 1997). There is often associated
cervical, thoracic or coccygeal pain. Sciatic pain is common
and may be of lumbar origin or from sacroiliac joint
involvement because the L5 and S1 components of the
lumbosacral plexus run immediately anterior to the sacro­
iliac joints. Several studies have differentiated between
pregnancy-related LBP and PGP (Ostgaard et al. 1994,
1996; Ostgaard 1997; Noren et al. 2002; Vleeming et al.
2004; Bastiaanssen et al. 2005; Gutke et al. 2006). It is
important that both the lumbar spine and pelvic girdle are
examined to determine the origin of symptoms and plan
appropriate management.
Causes of lumbopelvic pain appear multi-factorial and
may include postural adaptations, fatigue, increased joint
mobility, increased collagen volume causing pressure on
pain-sensitive structures, weight gain and pressure from
the growing fetus (Haslam 2004b). The main risk factors
are a history of previous lumbopelvic pain and/or previ­
ous trauma to the pelvis and possibly a high workload and
multiparity (Berg et al. 1988; Ostgaard and Andersson
1991; Kristiansson et al. 1996a; Larsen et al. 1999;
Vleeming et al. 2004). Others may include pelvic girdle
pain in a previous pregnancy (Larsen et al. 1999), poor
workplace ergonomics and awkward working conditions
(Larsen et al. 1999), abdominal sagittal and transverse
diameters and a naturally large lumbar lordosis (Ostgaard
et al. 1993), and also a decreased fitness level before preg­
nancy (Ostgaard et al. 1993). Factors not associated with
PGP include contraceptive pill use, time interval since last
pregnancy, height, smoking, age and breastfeeding (Berg
et al. 1988; Kristiansson et al. 1996b; Larsen et al. 1999).
Reported musculoskeletal factors contributing to
pregnancy-related PGP include the pelvic girdle joints
moving asymmetrically (Damen et al. 2001), symphyseal
laxity (Björklund et al. 1999) and ligamentous strain and
muscle weakness (Mens et al. 1996). PGP is probably
caused by a combination of these factors plus altered activ­
ity in the spinal (Sihvonen et al. 1998), abdominal, pelvic
girdle, hip (Pool-Goudzwaard et al. 1998) and pelvic floor
muscles (Pool-Goudzwaard et al. 2005) leading to abnor­
mal pelvic girdle biomechanics and stability. However, a
small number of women might have non-biomechanical
but hormonally-induced pain in the pelvic girdle.
Symphysis pubis dysfunction
Symphysis pubis dysfunction (SPD) relates to pain in the
region of the symphysis pubis joint whereas diastasis sym­
physis pubis (DSP) is a true separation of the symphysis
pubis joint confirmed radiologically. The definition of
DSP is symphyseal separation of more than 10 mm and
vertical shift of more than 5 mm (Hagen 1974). The
amount of symphyseal separation does not always
Chapter 27
correlate with symptoms (Snow and Neubert 1997) and
not all symptomatic patients have an increased gap. SPD
or DSP may occur antenatally, during delivery or postna­
tally, and might cause severe social difficulties (Fry 1999).
Trauma to the symphysis pubis may occur during a
difficult delivery where forceful and excessive abduction
of the thighs is necessary (Capiello and Oliver 1995;
Gherman et al. 1998; Heath and Gherman 1999; Kharrazi
et al. 1997; Albert et al. 2001).
Diagnosis of PGP
Pain distribution may be in the groin, medial and anterior
thighs, perineum, coccyx, and one or both sacroiliac joints
(Fry 1999; Coldron 2005). Severity and irritability vary
from mild to severe and may differ day-to-day. Common
physical signs are pain on thigh abduction, turning in bed,
lifting a light weight, getting up from a chair and using
stairs, a shuffling or waddling gait, severe symphyseal
tenderness and an inability to weight-bear unilaterally
(Fry 1999; Hansen et al. 1999). Self-reported pain loca­
tions in the pelvis, a positive posterior pain provocation
test and a sum of other provocation tests (compression/
distraction; Patrick-Faber test; palpation of the symphysis
pubis; palpation of the long dorsal ligament) were signifi­
cantly associated with disability and pain intensity in late
pregnancy (Robinson et al. 2010). Furthermore, distress
was significantly associated with disability. The active
straight leg raise (ASLR), fear-avoidance beliefs and the
number of pain sites were not associated with pain and
disability. Minor trauma, such as stepping down from a
kerb, may cause severe symphysis pubis pain. A forward
rotation and oblique slip of the innominate caused by
overactivity in the adductor muscles of the thigh may con­
tribute to SPD (Röst 1999). With poor use of the glutei
and lack of force closure of the pelvis, disruption of the
self-locking mechanism of the pelvis may occur.
Non-musculoskeletal causes of PGP
Proposed non-musculoskeletal factors for PGP include
increased hyaluronidase (Schwartz et al. 1985), oral con­
traceptives (Wreje et al. 1997) – although this is disputed
by Björklund et al. (2000b) – and genetic susceptibility
(MacLennan and MacLennan 1997). The role of relaxin
in production of pregnancy-related lumbopelvic pain is
controversial with some evidence suggesting an associa­
tion between relaxin and PGP (MacLennan et al. 1986b;
Kristiansson et al. 1996b) while other evidence shows
none (Albert et al. 1997; Björklund et al. 2000a).
Relaxin levels are at their highest during labour but fall to
almost non-pregnant levels by three days postpartum
(MacLennan et al. 1986a). As many women experience
postpartum lumbopelvic pain, other reasons apart from
serum relaxin levels probably contribute.
613
 Tidy’s physiotherapy
Conclusive association between new-onset postpartum
backache and epidural analgesia has not been demon­
strated (Breen et al. 1994; Russell et al. 1996; MacArthur
et al. 1997; Howell et al. 2002; Loughnan et al. 2002)
though its masking effect on pain may lead
to women adopting unsuitable positions in labour
(MacArthur et al. 1990).
Management of lumbopelvic pain
and dysfunction
It is important to acknowledge that pregnancy-related
lumbopelvic pain is a common, recognised condition,
which is better managed with prompt identification,
assessment and appropriate treatment. If left untreated it
may last more than two years (Albert et al. 2001).
Advice, posture, education and
general exercise
Antenatal education on posture and back pain by a physi­
otherapist has been shown to reduce back and pelvic pain,
reduce sick leave and continue to benefit women in the
postnatal period (Noren et al. 1997). Antenatal advice
includes adopting comfortable resting positions; moving
out of bed, a chair or the car; postures in walking and
standing; and correct lifting and handling. In addition,
postnatal advice includes positions for breastfeeding,
nappy changing, bathing and handling the growing baby.
Woman may be advised to (ACPWH 2010a):
• remain active within the limits of pain;
• accept offers of help and involve partner, family and
friends in daily chores;
• rest when needed;
• avoid standing on one leg;
• consider alternative sleeping positions;
• explore alternative ways to climb stairs;
• plan her day;
• avoid activities that involve asymmetrical positions
of the pelvis;
• consider alternative positions for intercourse;
• organise hospital appointments for the same day if
possible;
• avoid activities which make the pain worse (e.g.
vacuuming, pushing a supermarket trolley, lifting
heavy weights).
Liaison with midwives is essential. Women should be
aware of the masking effect of epidural and spinal anaes­
thesia in relation to excessive abduction of hips during
labour and delivery. If possible, they should adopt the
most comfortable position during labour (for example
left-side-lying, or kneeling upright with support). They
should be discouraged from placing their feet on attend­
ants’ hips and care should be taken if lithotomy is required
(ACPWH 2010a). Suturing should take place in the most
comfortable position for the mother.
614
Treatment of articular dysfunctions/
movement restriction of the spine and
pelvic girdle
There is some evidence that pregnancy-related lumbopel­
vic pain may respond to manual therapy (Daly et al. 1991;
Diakow et al. 1991; McIntyre and Broadhurst 1996), and
correct assessment of the spine and pelvic girdle is impera­
tive to enable treatment to be targeted at the correct struc­
tures. Providing severity and irritability has been properly
assessed, many manual therapy techniques in use in the
non-pregnant population can be used and adapted for
women with pregnancy-related lumbopelvic pain. Many
can be undertaken with the woman in side lying.
Management depends upon whether there is movement
limitation caused by a true articular restriction, or the joint
is held in an abnormal position by imbalance or altered
recruitment of the muscles (Lee and Vleeming 2000). Lee
(1999) recommended that articular restrictions be treated
first with mobilisation or manipulation techniques fol­
lowed by treatment of myofascial structures using muscle
energy techniques (MET). Other techniques for treating
myofascial dysfunctions include trigger points, strain/
counterstrain, positional release, soft tissue manipulation
techniques or taping to offload overactive muscles. Unilat­
eral or bilateral muscles that may be overactive with PGP
are the hip adductors, psoas, piriformis, erector spinae and
quadratus lumborum. Tightness may be palpated in the
posterior fibres of the pubococcygeus.
With SPD, special attention should be paid to overactive
pelvic adductors, underactive abductors, unilateral dis­
placement of one innominate bone (Röst 1999) and poor
pelvic girdle and spinal stabilising muscles.
The use of a sacroiliac/trochanteric belt for sacroiliac
and symphysis pubis instability both ante- and postnatally
may stabilise the pelvic girdle joints (Damen et al. 2002;
Mens et al. 2006) and substitute the work of the internal
oblique muscle (Snijders et al. 1998) but its effect on pain
is equivocal (Depledge et al. 2005). However, a belt
should be tried if ASLR test is positive. A large tubular
bandage for the abdomen or a maternity belt may give
added support. In the most severe cases crutches or a
wheelchair may be required.
Muscle re-education
Abdominal, spinal and pelvic girdle muscle motor control
needs to be retrained to stabilise an unstable spinal
segment or pelvic girdle joint. Specific spinal and pelvic
girdle stabilising programmes are effective in reducing
pain antenatally (Elden et al. 2005) and postnatally (Stuge
et al. 2004a, 2004b, 2006).
Rehabilitation exercises antenatally and postnatally
should concentrate initially on correct recruitment and
strength training of both pelvic girdle stabilising muscles
(gluteus medius and maximus) and core lumbopelvic
stabilising muscles (transversus abdominis, lumbar
 Physiotherapy in women’s health
multifidus, pelvic floor muscles). Poor recruitment and
decreased strength of hip adductors and flexors have been
shown to be a factor in pregnancy-related PGP (Mens et al.
2002), and altered recruitment of gluteus maximus has
been shown in patients with sacroiliac joint (SIJ) pain. No
studies of gluteus medius in pregnancy-related PGP have
been undertaken, but the waddling gait of these patients
is a common sign and is probably a result of poor gluteus
medius control. It is proposed that the main muscles to
be targeted in women with PGP are the trunk core stability
muscles, as described above, plus the hip abductors,
adductors, flexors and extensors. Consideration of the
balance between adductors and abductors should be given
owing to their function in providing stability across the
symphysis pubis (Lee 1999). Exercise for global stabilising
muscles, such as the oblique abdominals, erector spinae,
latissimus dorsi and iliopsoas should follow as pain and
physical ability allows. The role of RA in lower abdominal
strength and support should not be ignored as Coldron
et al. (2008) found that characteristics of RA shape and
size had not returned to normal values by 12 months
post-partum. A thinner, wider and longer RA has implica­
tions for strength and fascial support, and may cause
decreased stiffness of the anterior abdominal wall and
predispose to a mechanical disadvantage. Exercises that
target the return of normal RA width, thickness (strength)
and length without loading and compressing the lumbar
spine are required.
Rehabilitation exercises need to be functional, as many
women cannot regularly attend a physiotherapy depart­
ment owing to family commitments. During pregnancy
women should be encouraged to retain their cardiovascu­
lar fitness where possible and, if necessary, increase it
postpartum.
Management of diastasis rectus
abdominis
The consequences of a persistent diastasis rectus abdominis
(DRA) are not known fully but a relationship between
DRA and diagnoses of stress urinary incontinence, faecal
incontinence and pelvic organ prolapse has been shown
(Spitznagle et al. 2007). It is also possible that the
mechanical advantage of the two RA bellies is compro­
mised and thus could affect muscle strength and potential
development of lumbopelvic pain. The IRD should resolve
to approximately 20 mm by 8 weeks postpartum (Coldron
et al. 2008) which approximates to 1–2 finger widths.
However, in some women the IRD does not return to
normal values by 12 months postpartum (Coldron et al.
2008) and, together with the changes to RA, anterior
abdominal wall stiffness is likely to be compromised.
Physiotherapists should examine the postnatal gap be­­
tween the recti at the level of the umbilicus and assess
the IRD. If there appears to be a persistent DRA (>3
finger widths) advice regarding exercise should be given,
Chapter 27
including initial training of the deep abdominal muscles
(TrA) (Sheppard 1996; Potter et al. 1997a), gentle exer­
cises to strengthen RA while avoiding strong trunk curling
exercises to prevent herniation of abdominal contents.
In a small study, the occurrence and size of DRA in preg­
nant women was found to be much greater in non-
exercising pregnant women than in those who exercised
(Chiarello 2005) supporting the view that good fitness
pre-pregnancy is of benefit to the woman.
Pain management
There is increasing evidence that acupuncture is effective
in relieving antenatal lumbopelvic pain (Wedenberg
et al. 2000; Ternov et al. 2001, Guerreiro da Silva et al.
2004; Kvorning et al. 2004; Elden et al. 2005; Lund et al.
2006) and recent evidence suggests that acupuncture has
no observable adverse effects on the pregnancy, mother,
delivery or the fetus/neonate (Elden et al. 2008). Some
experts advise that it is avoided in the first trimester
(Forrester 2003) and acupuncture points that have been
traditionally associated with abortion (miscarriage)
should also be avoided (Betts 2003; West 2008), though
this latter point is controversial as no adverse effects have
been reported.
The use of TENS antenatally for pain relief is controver­
sial owing to concerns about fetal malformations and
spontaneous abortion, but no negative effects have been
reported from the use of TENS during any stage of preg­
nancy (ACPWH 2007). Therefore, its use in pregnancy
for lumbopelvic pain could be justified provided the
usual precautions and contraindications are observed, the
current density is kept low, large electrodes are used, elec­
trodes are not placed over the abdomen and acupuncture
points thought to induce labour are avoided. Although the
evidence for pain relieving effects of TENS is equivocal
(Khadilkar et al. 2008) it poses less risk than most anal­
gesic medicines, so could be tried.
Rib pain
Pain along the anterior surface of the lower ribs (possibly
related to pressure from the ascending uterus, and com­
monly called ‘rib flare’) may be accompanied by thoracic
spine and lateral chest pain. This may be relieved by side
flexion manoeuvres away from the pain and manual
therapy techniques.
Nerve compression syndromes
Fluid retention may occur during the third trimester,
which can lead to a variety of nerve compression syn­
dromes. These include carpal tunnel syndrome (CTS),
brachial plexus compression, meralgia paraesthetica
(compression of the lateral cutaneous nerve of the thigh
as it passes under the inguinal ligament, presenting as
tingling and burning in the outer thigh) and posterior
615
 Tidy’s physiotherapy
tibial nerve compression. These entrapments normally
resolve postpartum.
Wrist splints and ice are useful for CTS. Postural advice
can be used for brachial plexus compression. Ice and ele­
vation may help posterior tibial nerve compression
(Polden and Mantle 1990).
EXERCISE AND PREGNANCY
General issues
Physiological, emotional, social and psychological issues
influence physical fitness in pregnancy. Physiotherapists
must be sensitive towards these, and be aware of other
issues, such as language, ethnic cultures, equal opportuni­
ties and women with special needs. The therapist’s
approach to pregnant women should be holistic, flexible,
individual, and – where available – evidence-based.
Many women exercise regularly and wish to continue
during pregnancy. Some women take up exercise for the
first time, and exercise should be encouraged during
pregnancy (RCOG 2006). Special guidelines for safe
activity and exercise in pregnancy exist for women
with weight-management problems, diabetes and pre-
eclampsia (CMACE/RCOG 2010; NICE 2010a). Health
professionals should use any appropriate opportunity to
provide information about the health benefits of losing
weight before becoming pregnant to women with a body
mass index (BMI) ≥30. This should include information
on the increased health risks their weight poses to them­
selves and would pose to their unborn child.
Research suggests that mild-to-moderate exercise is ben­
eficial to healthy pregnant women (Clapp 2000) and is not
harmful to the fetus (Clapp et al. 2000; Riemann and
Kanstrup Hansen 2000; ACOG 2002; Arena and Maffulli
2002). Moderate intensity is defined as being able to talk
easily, while increasing the heart rate to a maximum of 140
beats per minute. Choice of exercise must be influenced by
the physiological changes which will occur (Artal and
O’Toole 2003). For example, plasma volume increases
before red cell volume, leading to a decreased ability to
provide oxygen in response to demand. Also, increased
demand causes raised respiratory rates, cardiac output
values increase during pregnancy for the same activity
(over the non-pregnant woman) and there is a loss of
cardiac reserve.
Benefits and contraindications
Potential benefits of exercise include:
• maintenance of cardiovascular fitness;
• maintenance of healthy weight range;
• improvement of body awareness, posture,
co-ordination and balance;
616
• improvement in circulation;
• increase in endurance and stamina;
• provision of social interaction with exercise,
enhancing feelings of social and emotional
well-being;
• possible reduction in problems during labour and
delivery;
• potentially shorter labour;
• possible prevention of gestational diabetes;
• reduction in minor complaints of pregnancy;
• more rapid postnatal recovery.
Contraindications to exercise include:
• cardiovascular, respiratory, renal or thyroid disease;
• diabetes (type 1, if poorly controlled);
• history of miscarriage, premature labour, fetal growth
restriction, cervical incompetence;
• hypertension, vaginal bleeding, reduced fetal
movement, anaemia, breech presentation, placenta
praevia (ACOG 2002).
Advice
The advice given to regular and non-regular exercisers will
differ.
Regular exercisers
• Consult your doctor or midwife before beginning
exercise.
• Exercise at a moderate level most days for 30
minutes or more (Hefferman 2000; RCOG 2006).
• Discontinue contact sports and activities which carry
a high risk of falling or abdominal trauma. Avoid
scuba diving (RCOG 2006).
• Self-regulate both the level of intensity and duration
of exercise, aiming to keep core temperature below
38°C.
• Aim for low impact activity.
• Wear suitably supportive footwear to reduce
musculoskeletal stresses.
• Maintain adequate fluid intake to prevent
dehydration, and avoid exercise during hot and
humid weather, or with pyrexia.
• Warm-up and cool-down for at least five minutes.
• Do not use developmental stretching (because of the
effects of relaxin).
• Seek professional advice on specific exercises (e.g. for
the pelvic floor muscles).
• Avoid ballistic exercise, low squats, crossover steps
and rapid changes of direction.
• Do not exercise in supine after 16 weeks gestation,
to avoid aortocaval compression.
• Eat to appetite, without calorific restriction.
• Work towards cross-training to avoid over-training,
and stop exercise before fatigue sets in.
 Physiotherapy in women’s health
Non-regular exercisers
In addition to the above, women not used to regular exer­
cise should be advised:
• not to start an exercise programme until >13 weeks
gestation;
• to consider beginning with non-weight-bearing
exercises, such as aquanatal classes;
• to progress from simple and basic levels of exercise,
increasing exercise tolerance gradually, under the
supervision of a suitably qualified professional.
When to stop
All women should stop exercising immediately and seek
advice from a doctor if they experience:
• abdominal pain;
• per vaginum (from the vagina) bleeding;
• shortness of breath, dizziness, faintness, persistent
severe headache, palpitations or tachycardia;
• PGP, which may also lead to difficulty in walking.
Most women will naturally reduce the amount of
exercise they take during pregnancy as their weight
increases, and they fatigue and become breathless more
rapidly.
Types of exercise
General categories
• Leisure sports. Provided the contraindications have
been noted and the woman is familiar with her
chosen activity, it is safe to continue pursuing
leisure sports. These may include brisk walking,
swimming, jogging, hiking, rowing and dancing.
The pace adopted should be sufficient to cause
aerobic changes. If PGP is a problem, avoid the
kicking motion of the legs during breast stroke
swimming.
• Low impact aerobics (or equivalent classes). The
emphasis is on maintaining fitness levels.
• Pilates or yoga (modified for pregnancy) cater for the
non-aerobic elements of fitness – flexibility, control
of breathing and relaxation.
• Back care classes. Core stability exercises may be
taught, sometimes using a Swiss ball.
• Gym work. The pregnant woman may have access to
a static bicycle, treadmill or cross-trainer, all of which
encourage aerobic activity. Technique is especially
important when strength training. Women should
use light weights, with submaximal lifts, aiming to
use both upper and lower body muscle groups in a
variety of exercises. Weights, sets and repetitions
should be decreased further as pregnancy progresses
(Avery et al. 1999)
Chapter 27
Aquanatal classes
Pregnant women may find exercise and relaxation in
water enjoyable and beneficial, largely because of the
feeling of weightlessness and the reduced jarring of the
joints. It has been suggested that women submerged to
the xiphisternum will experience only 28% of their
body weight (Harrison and Bulstrode 1987). Women in
aquanatal classes may get relief from aches and pains, feel
they have more energy after and sleep better. Another
important benefit is the absence of post-exercise muscle
soreness because, during immersion, all muscle work is
concentric (Newham 1988). Other significant advantages
are less obvious to the woman: exercise in water helps to
tone the respiratory muscles; the leg movements of swim­
ming and exercise in water aid venous return; and the
diuretic effect of immersion is helpful to pregnant women
troubled by fluid-retention, as immersion for 20–40
minutes results in a loss of 300–400 ml of fluid (Katz
et al. 1991).
Women must be screened for contraindications and for
any musculoskeletal problem of which the teacher should
be aware (ACPWH 2010c). The water temperature should
be between 28 and 32°C (ACPWH 2010c).
Exercises can be amended for someone with a muscu­
loskeletal problem. Women with PGP may be more com­
fortable if they modify their breast stroke leg movements
and take small, rather than wide, steps sideways. All
women should take short backward steps to avoid an
increase in lumbar lordosis. Exercises that overstretch the
already compromised abdominal muscles should be
excluded. Conversely, squatting, which is difficult on land
and thought by some to be damaging, is safe in water as
virtually no weight goes through the knee joints.
The aim of the class is to help maintain, not improve, a
woman’s level of fitness. Exercises must be safe and care­
fully chosen, and each included for a reason. Water exer­
cises should be considered in their own right and not
taken unchanged from exercise classes on land (Evans
2002). It is necessary to warm-up in the water before start­
ing aerobic and strengthening exercises. Buoyancy can be
used to assist movement and to make the exercises easier,
or to resist movement and allow muscle-strengthening.
Pelvic floor muscle exercises should be included before,
during or at the end of the class. Good posture should be
taught at the beginning of the class and participants
reminded to maintain it throughout the class. If the water
is warm enough, a relaxation session is an excellent way
to end the class.
ANTENATAL CLASSES
It is recommended that all pregnant women receive appro­
priate antenatal advice and information (NICE 2008b),
including access to parenting education, and preparation
617
 Tidy’s physiotherapy
for birth classes (DH 2004). A physiotherapist has been
identified as a member of the MDT (DH 2004).
Midwives, physiotherapists and other healthcare pro­
fessionals typically work together to provide antenatal
education in the form of classes and group activity. The
sessions take many formats, and vary in number and
timing. They should provide high-quality advice and
information at a convenient time in a location that is
accessible, and in a format that is appropriate to the needs
of the woman and anyone who might accompany her.
Historically, women’s health physiotherapists participated
in several classes, but within recent years this has been
decreased in many places (if not stopped). Therefore, for
many, an additional challenge is to include the most per­
tinent information within a limited time, in particular
topics that relate to the unique knowledge and skills of
physiotherapists.
‘Early bird’ groups may be held in early pregnancy;
however, historically, the majority of women attend classes
in the third trimester. Classes may be for first-time mothers
or for women who have had previous pregnancies; com­
monly they include a mixture of both. There may be spe­
cific classes, for example for twin pregnancies, for teenagers
and for non-English-speaking women.
The physiotherapist must choose the class content to
suit her/his audience and might include:
• advice on safe exercise;
• back and pelvic girdle care;
• pelvic floor and abdominal exercises;
• activities of daily living and work;
• management of pregnancy-related musculoskeletal
dysfunctions;
• coping strategies for labour, e.g. relaxation, positions
of comfort, breathing awareness;
• advice on early postnatal exercises and return to
fitness.
Other sections of this chapter (e.g. ‘Labour’, ‘Birth and
the puerperium’, ‘Physiotherapy in the childbearing year’,
‘Exercise and pregnancy’, ‘Urogenital dysfunction’) provide
more information on what might be included in antenatal
classes.
POSTNATAL PHYSIOTHERAPY
The role of the physiotherapist in the days, weeks and
sometimes even months following the birth includes
advice for new mothers on how to regain and perhaps
improve their former level of fitness through appropriate
exercise and education. Also included are the assessment
and treatment of specific physical problems, emotional
support and health education. Although it might be
considered the ideal for every woman to be advised
by a women’s health physiotherapist postnatally, this is
becoming increasingly uncommon. Many women will
618
not be seen by a physiotherapist, but should be given
appropriate advice by a midwife and high-quality written
information.
Inpatient postnatal physiotherapy, if offered, may
include the following:
• caesarean section – early mobility, bed exercises if
indicated, treatment of respiratory complications,
pelvic floor muscle and abdominal exercises;
• perineal trauma – physiotherapeutic interventions
might include advice, exercises, ice or appropriate
electrotherapy;
• incontinence – training in PFM exercises by a
physiotherapist postnatally, incorporating strategies
to improve compliance, has been shown to reduce
the incidence and severity of urinary incontinence
(Chiarelli and Cockburn 2002), and the effect of
postnatal pelvic floor muscle training on the
prevention and treatment of stress urinary
incontinence has been shown to endure one year
after delivery (Mørkved and Bø 2000). Persistent
pelvic floor dysfunction should be treated (see
section on urogenital dysfunction). Incontinence of
stool can also occur and is more prevalent among
women who experienced a third-degree (partial
or complete disruption of the anal sphincter) or
fourth-degree tear (complete disruption of the
external and internal anal sphincter and epithelium)
during delivery (Eason et al. 2002; see section on
anorectal dysfunction).
• musculoskeletal problems – see the earlier section on
musculoskeletal problems in the childbearing year.
Postnatal groups
Physiotherapists may also participate in hospital- or
community-based postnatal groups offering advice and
appropriate exercise. Stress-free physical activity is associ­
ated with a reduced likelihood of developing postnatal
depression (Koltyn and Schultes 1997) and may help
women return to pre-pregnancy levels of fitness.
UROGENITAL DYSFUNCTION
Problems relating to the female urinary and genital tracts
are common and often complex. The problems encoun­
tered most frequently by physiotherapists are bladder dys­
function and pelvic organ prolapse.
Bladder dysfunction
Most common is urinary incontinence, which may occur
at any time in a woman’s life but rises in incidence with
age. A study of women aged 50–74 found that some
 Physiotherapy in women’s health
leakage of urine was reported by 47% and regularly by
31% (Holtedahl and Hunskaar 1998); other authors
report similar findings. Although there are several types of
urinary incontinence, this chapter will concentrate on
those most commonly treated by the women’s health
physiotherapist.
Stress urinary incontinence (SUI) is defined as the com­
plaint of involuntary leakage on effort or exertion, or
on sneezing or coughing (ICS 2002). This is the most
common type of incontinence and may coexist with
overactive bladder. The urethra has to remain closed and
sealed, except during voluntary bladder emptying. Conti­
nence is maintained by urethral closure pressure, which
must remain higher than detrusor (bladder muscle)
pressure, both at rest and on physical exertion. Physical
effort causes a sudden rise in intra-abdominal pressure,
which is transmitted to the bladder. When pressure in
the bladder rises above that of the urethra, there will be
an involuntary escape of urine. The pelvic floor muscles
(PFMs) contribute significantly to the continence mecha­
nism, providing about one-third of urethral closure
pressure (Raz and Kaufman 1977; Rud et al. 1980).
Urgency urinary incontinence (UUI) is involuntary leakage
accompanied by, or immediately preceded by, urgency;
that is, a sudden compelling desire to pass urine, which is
difficult to defer (ICS 2002). This form of leakage occurs
when the detrusor contracts inappropriately as the bladder
fills (overactive bladder). Urinary urgency, frequency and
nocturia (waking to pass urine during the night) can exist
without leakage, and may be deemed troublesome by
women. Although UUI may be idiopathic, the symptoms
can have a neurological cause, for example multiple scle­
rosis (see below).
Mixed urinary incontinence describes a mixture of SUI
and UUI.
Neurogenic detrusor overactivity describes bladder dys­
function of neurological origin (ICS 2002). Women com­
monly report symptoms as described above under urgency
urinary incontinence.
Pelvic organ prolapse
Pelvic organ prolapse (POP) is the descent of one or
more of the anterior/posterior vaginal wall; apex of the
vagina (cervix, uterus); or vault (cuff) after hysterectomy
(ICS 2002). It may be further categorised from stage 1
(least) to stage 4 (most) severe. Symptoms may include
the feeling of a lump (‘something coming down’) or heavi­
ness in the vagina, and urinary or bowel symptoms may
coexist.
POP occurs when the fibromuscular supports of the
pelvic organs fail. Studies suggest that 50% of parous
women (those who have had children) have some loss
of PFM support (Bø 2006) which might contribute to
POP, though not all will be symptomatic, with a re­­
ported incidence of 4–12.2% (Tegerstedt et  al. 2005).
Chapter 27
Severity increases with age and number of vaginal births
(Rortveit et  al. 2007).
Factors contributing to urogenital
dysfunction
It is widely accepted that urogenital problems are
associated with vaginal delivery (Wilson et al. 1996;
Toozs-Hobson 1998). For many women, childbirth is
probably the most significant factor contributing to
the development of symptoms. Allen et al. (1990) suggest
that a woman’s first vaginal delivery causes muscle,
fascial and nerve damage, and it is likely that further
damage will occur with future deliveries. Chiarelli and
Campbell (1997) suggest that forceps delivery increases
this risk. There are other reported risk factors: pregnancy
itself, straining at stool, heavy lifting, inappropriate
exercise, chronic cough, obesity, pelvic surgery, hormonal
status and ageing.
Risk factors for POP include symptoms during preg­
nancy, a maternal history of POP and heavy physical
work (Slieker-ten Hove et  al. 2008). The same author
reports risk factors identified in earlier studies, including
previous hysterectomy, surgery for urinary incontinence
and/or POP, education, family history, lung disease,
smoking, BMI, hormone replacement therapy, race and
medication. Brækken et  al. (2009) also found a link
with pelvic floor muscle function.
Physiotherapy
The role of physiotherapy in the management of urogeni­
tal dysfunction is well established and largely evidence-
based. The National Institute for Health and Clinical
Excellence (NICE 2006) states that the first-line treatment
for women with stress or mixed urinary incontinence
should, following digital assessment of the muscle con­
traction, be a trial of supervised pelvic floor muscle train­
ing (PFMT) for at least three months. Without digital
examination (i.e. verbal or written instructions) many
women may not be contracting the muscles correctly
(Bump et al. 1991). PFMT has been shown to be effective
for women with stress (Dumoulin and Hay-Smith 2010;
Imamura et al. 2010) and all types (Dumoulin and
Hay-Smith 2010) of urinary incontinence. It appears to
be most effective when intensive (Imamura et al. 2010).
Brækken et al. (2010) showed that PFMT can be an
effective treatment for POP, without adverse effects.
Pelvic floor muscle training
It has been suggested that PFMT is effective for women
with stress urinary incontinence by building up long-
lasting muscle volume which provides structural support
(Bø 2004). In addition, women are advised to contract
619
 Tidy’s physiotherapy
their PFMs before and during coughing, sneezing, etc.,
which has been shown to reduce leakage in women with
stress urinary incontinence (Miller et al. 2008). Although
a PFM contraction is normally accompanied by co-
contraction of transversus abdominis (TrA) there is, to
date, insufficient evidence for the use of TrA training
instead of, or in addition to, PFMT for women with urinary
incontinence (Bø et al. 2009).
Many widely differing exercise protocols are described
in the literature. Bø (2007) advises close to maximum
contractions, building up to 8–12 three times a day, and
weekly supervised training. The ACPWH (2009) suggests
both long and short squeezes, three times a day.
Teaching PFM exercises
It is important that physiotherapists can teach a pelvic
floor contraction, particularly when they do not have the
opportunity to examine a woman to check her technique
(e.g. antenatal classes). The following instructions have
been suggested (ACPWH 2009):
1. Imagine you are trying to stop yourself from passing
urine and breaking wind
2. Squeeze tightly inside your vagina
3. Lift and squeeze.
It has been suggested that imagery may help women
contract correctly (Bø and Mørkved 2007):
1. A lift or elevator – closing the doors (squeeze) and
moving up (lift)
2. Eating spaghetti
3. Action of a vacuum cleaner.
Biofeedback
Biofeedback may be via electromyography, a pressure
sensor or real-time ultrasound. The woman receives im­­
mediate visual information regarding her pelvic floor
activity and may be able to modify/increase her effort
accordingly. It has been suggested that PFMT with bio­
feedback is an effective treatment for women with stress
urinary incontinence (Imamura et al. 2010). Vaginal cones
also constitute a form of biofeedback and are used by
some physiotherapists as an adjunct to PFMT. Recent
studies (Castro et al. 2008; Gameiro et al. 2010) suggest
that they are no more effective that PFMT.
Electrical stimulation
Electrical stimulation (ES) has been suggested as a treat­
ment for stress urinary incontinence (Laycock 2003) or
overactive bladder (Yamanishi et al. 2000). Goode et al.
(2003) showed that the addition of ES to a comprehensive
behavioural programme for women with SUI did not
increase the effectiveness of treatment. If used, ES may be
applied in a physiotherapy department, or used at home.
620
Behavioural modification
Physiotherapy interventions normally include advice, and
the management of urogenital dysfunction is no excep­
tion. Women with SUI might be advised on weight-loss,
adjustment of fluid intake, smoking cessation, exercise
modification and regularisation of bowel habit (Imamura
et al. 2010). For POP, advice might include avoidance of
heavy physical work, lung disease and smoking, which
have been suggested as risk factors for the condition
(Slieker-ten Hove et al. 2008).
Men
Bothersome lower urinary tract symptoms (LUTS) are
present in up to 30% of men aged over 65 years and
supervised pelvic floor muscle training is recommended
for men with stress urinary incontinence caused by pros­
tatectomy (NICE 2010b). Men receiving physiotherapist-
guided PFMT following radical prostatectomy have been
shown to experience reduced urinary incontinence one
year after surgery, compared with patients who exercised
on their own (Overgård et al. 2008).
ANORECTAL DYSFUNCTION
Physiotherapists might also treat anorectal dysfunctions
such as faecal incontinence and constipation.
Faecal incontinence
Involuntary loss of flatus or stool may affect 11–15% of
the population (Macmillan et al. 2004), being most preva­
lent in older people in care. It can have a negative impact
on quality of life (Madoff et al. 2004). Causes are similar
to those listed under urogenital dysfunction – the most
common being obstetric trauma. Leakage is described as
passive (patient not aware) or urge (patient is aware of a
need to defaecate, but is unable to control it). Arguably,
of greatest significance is the consistency of stool. If liquid
or very soft, it is far more difficult to contain. Ideally, the
referring doctor will have addressed this issue.
Sphincters
The internal anal sphincter comprises smooth muscle, and
provides 80–85% of resting pressure. The external anal
sphincter (EAS) is under voluntary control and contracts
in response to rectal distension to allow the individual to
defer defaecation until an appropriate time. Puborectalis,
part of the levator ani, also contributes to the continence
mechanism, by forming an acute angle at the top of the
anal canal (anorectal angle) to prevent the escape of rectal
contents.
 Physiotherapy in women’s health
Physiotherapy
NICE (2007) recommends specialist management for
sufferers whose symptoms are not relieved by simple
advice. This management includes PFM training, biofeed­
back and electrical stimulation, all within the scope of
the specialist physiotherapist. A recent review (Norton
et al. 2010) recommends that further research is under­
taken on these interventions to prove their effectiveness.
Constipation
Constipation has been reported to affect between 2% and
34% of adults, and a literature review (D’Hoore and
Penninckx 2003) has suggested that obstructed defaeca­
tion (see below) specifically affects 7%. Constipation may
be defined as infrequent bowel motions (fewer than
three times a week) or the need to strain at defaecation.
It may be subdivided into slow-transit and obstructed
defaecation.
Slow-transit constipation may be idiopathic, but can be
a result of the avoidance or postponement of defaecation
by an individual, among other causes. It has been claimed
(Gattuso and Kamm 1993) that up to 50% of patients
with severe idiopathic constipation may have a history of
childhood bereavement or of emotional, sexual or physi­
cal abuse.
Obstructed defaecation is an inability to evacuate the
rectal contents and the cause may be anatomical or func­
tional. The latter may be a failure to relax puborectalis
(pelvic floor dyssynergia) or the EAS, or a lack of pelvic
floor support (and resulting descent of the perineum)
during defaecation (Markwell and Sapsford 1995). Causes
are many, including obstetric trauma, pelvic surgery
and prolonged straining. As with slow transit, researchers
have suggested an association with sexual abuse (Leroi
et  al. 1996). Obstructed defaecation may be found in
combination with slow transit (Hutchinson et  al. 1993).
Physiotherapy
The aim of physiotherapy is to teach effective defaecation
without straining (Markwell and Sapsford 1995) and
should include correct positioning on the toilet, relaxation
of puborectalis and the EAS, and optimum abdominal
muscle action with an expulsive effort. Biofeedback might
also be used and reviews of the literature (Bassotti et al.
2004; Chiarelli 2008) concluded that, although controlled
trials were few and open to criticism, patients with
obstructed defaecation owing to pelvic floor dyssynergia
may benefit from biofeedback. Further research was rec­
ommended. If there is evidence of perineal descent or a
rectocele, women might be advised to offer manual
support to the perineum or digital support to the posterior
vaginal wall, respectively, to facilitate defaecation. As there
is an increase in colonic transit following meals, patients
Chapter 27
can be encouraged to attempt defaecation at these times.
Abdominal massage may also be used and has been shown
to decrease symptoms of constipation when used along­
side medication (Lämås et al. 2009).
GYNAECOLOGICAL SURGERY
Gynaecological surgery may be necessary for many reasons,
including the removal of benign or malignant tumours,
urogynaecological conditions (if they fail to respond to
physiotherapy) and the treatment of problems related to
fertility or ectopic pregnancy. The physiotherapist should
be aware of the indication for surgery.
Physiotherapy
The physiotherapist may be part of the multi-disciplinary
team providing pre-operative advice and intervention
postoperatively to ensure safe discharge from hospital and
health education for life.
The enhanced recovery after surgery (ERAS) programme
enables patients to recover from surgery and leave hospital
sooner by minimising the stress responses on the body
during surgery (DH 2010). Pre-operative intervention
ensures that the patient is in the best possible condition
for surgery and aware of self-help strategies postopera­
tively. Early postoperative rehabilitation will help to
prevent venous thrombo-embolism (VTE), chest infection
and digestive problems. ERAS recommends that rehabili­
tation services are available seven days a week.
Pre-operative care
Ergonomic advice for home and work, sports and leisure,
postural care, abdominal and pelvic floor exercise and
relaxation should be provided, preferably pre-operatively,
and, ideally, before admission to hospital. This offers
patients an opportunity to organise changes at home and
inform employers how long they may be away from
their usual work. Groups are good use of the physio­
therapist’s time and offer a forum for peer support and
discussion. It is important to provide good written infor­
mation (ACPWH 2010b; RCOG 2010).
Physiotherapists should know each woman’s history, to
be aware of any relevant information (e.g. diagnosis of
malignancy). Special attention should be given to the
psychosocial and psychosexual effects of gynaecological
surgery on the patient and her family. Referral to other
professional groups, for example a Macmillan nurse or a
social worker, may be appropriate.
The physiotherapist might include:
• assessment of risk factors (e.g. respiratory conditions,
VTE risks, impaired mobility, current medication,
etc.) (NICE 2010c);
621
 Tidy’s physiotherapy
• identification of urogenital or anorectal dysfunction;
• identification of musculoskeletal problems;
• exercises and strategies to promote postoperative
mobility and comfort;
• postoperative recovery plan, both before and after
discharge from hospital;
• relaxation.
Postoperative care
The presence of an intravenous infusion, urinary catheter
(suprapubic or urethral), patient-controlled analgesia
and vaginal pack should be noted. The physiotherapist
must be aware of the findings at surgery, and their poten­
tial physical and psychological impact on the patient.
There may be concerns about relationships or resuming
sexual activity, and referral to the relevant professional
may be appropriate (Sacco Ezzell 1999). The physiother­
apist should assess and advise on:
• respiratory function – especially for those with
pre-existing problems;
• circulation – particularly for patients with limited
mobility and/or risk of deep vein thrombosis;
• mobility, comfort and posture – including bed
exercises and transfers, if appropriate;
• urination and defaecation – may include advice on
position on the toilet and wound support;
• abdominal exercises to help reduce discomfort when
moving, and ease and low back pain or flatus;
• pelvic floor muscles (PFMs) – the physiotherapist
should confirm with the consultant any local policy
for commencement of pelvic floor exercises (Jarvis
et al. 2005). Women who have undergone surgery
for prolapse and/or incontinence may already have
poor connective tissue. They should be given
appropriate advice – correct lifting techniques,
avoidance of standing for long periods, awareness of
the role of the pelvic floor and its interaction with
transversus abdominis (Britnell et al. 2005);
• going home – discharge from hospital may be very
early following some surgery, though it can be
considerably longer. Convalescence is usually for 4–8
weeks, with a gradual increase in physical activity,
but heavy lifting should be avoided for at least 6
weeks (RCOG 2010).
PELVIC PAIN
Acute and chronic pain
Pelvic pain in women has many varied sources, diagnoses
and outcomes. It can be acute or chronic. Acute pain
usually has an easily identifiable cause, such as dys­
pareunia (pain on sexual intercourse) caused by scar
622
tissue following childbirth. Appropriate treatment will
alleviate it.
When pain has lasted more than six months it is
termed chronic. Although it may still have a well-defined
cause (e.g. endometriosis), it can involve a much more
complex interplay between biomechanical, behavioural,
emotional and sociocultural influences, all of which need
to be taken into account in treatment. Subsequently, clini­
cians advocate a multi-disciplinary integrated approach
(Peters et al. 1991; Steege et al. 1998;). Good quality re­­
search is scarce for the multiple treatment modalities
advocated (Stones et al. 2005); however, physiotherapy is
included in the multi-disciplinary team (Fall et al. 2010).
Clinical note
The annual prevalence of chronic pelvic pain has been
estimated at between 24.4 cases per 1000 women
(Davies et al. 1992) and 38.3 per 1000 (Zondervan et al.
1999). The economic burden to the National Health
Service (NHS) may be £158 million, with indirect costs of
a further £24 million (Davies et al. 1992).
Pelvic pain has traditionally been ascribed (from a
gynaecological view) to endometriosis, pelvic inflamma­
tory disease, adhesions secondary to infection or surgery,
and – more recently – pelvic venous congestion. The most
important non-gynaecological cause is irritable bowel
syndrome. Other causes include ilio-inguinal nerve entrap­
ment, levator ani syndrome, coccydynia, interstitial
cystitis, vulval vestibulitis/vulvodynia and musculoskeletal
dysfunction.
Two studies showed that between 28% and 61% of
patients never received a diagnosis (Mathias et al. 1996;
Zondervan et al. 1999). This is highly significant as suffer­
ers often feel that their pain has not been validated and
will not be taken seriously until they have a diagnosis
(Grace 1995). This may result in a fruitless round of
clinicians.
Physiotherapy
The role of physiotherapy is to decrease pain, increase
function and treat existing (and help prevent future) mus­
culoskeletal dysfunction.
Following a detailed musculoskeletal examination,
including assessment of the pelvic floor muscles, appro­
priate treatment modalities will be agreed, according
to the needs of the patient and the experience of the
clinician involved. Close liaison with other members of
the MDT is essential to maximise the benefit of treatments
which might include muscle imbalance work, muscle
energy techniques, core stability exercises, pelvic floor
 Physiotherapy in women’s health
muscle rehabilitation, electrical stimulation, soft-tissue
mobilisations, joint manipulation, breathing and relaxa­
tion techniques, heat/cold therapy, hydrotherapy, biofeed­
back and alternative therapies.
MENOPAUSE
Menopause is the cessation of menstruation and marks the
end of a woman’s reproductive years. It has significant
implications for a woman’s health and quality of life, so
is of great relevance to the physiotherapist.
Most women experience the menopause between the
ages of 40 and 58 years, with a median age of 52 years
(NIH 2005). Therefore, with an average life expectancy of
81.9 years (ONS 2010a) women in the UK can expect to
enjoy about 30 years of postmenopausal life.
Biochemical and metabolic changes following meno­
pause may cause distressing symptoms that adversely
affect quality of life. The perimenopause describes the
period during which ovarian function declines, the men­
strual cycle becomes erratic and a woman may experience
symptoms of oestrogen depletion which include:
• vasomotor effects – hot flushes and night sweats;
• vaginal dryness which may result in painful
intercourse;
• sleep disturbance.
There are other symptoms which have been attributed
to the menopause, but which are yet to be substantiated
conclusively by research (NIH 2005):
• mood changes – depression, anxiety, irritability;
• cognitive disturbances, e.g. forgetfulness;
• somatic symptoms, e.g. back pain, stiff and painful
joints, tiredness;
• urinary incontinence;
• menorrhagia (heavy bleeding);
• sexual dysfunction;
• quality of life – either positive or negative effects.
Oestrogen, or oestrogen combined with progestogen,
have been shown to have a positive effect on vasomotor
symptoms, but studies have identified risks associated
with their use (NIH 2005). Botanical products such as
black cohosh and red clover are also taken by some
women, but studies have not been the most robust so
further research is advised (NIH 2005).
In relation to the physiotherapist, exercise, health edu­
cation, acupuncture and breathing techniques may confer
some benefit (NIH 2005; Roberts 2007).
BREAST CANCER
Breast cancer is the most common cancer affecting women
in the UK with an average of 1 in 9 women being
Chapter 27
diagnosed. In 2007, 45,700 new cases of breast cancer
cases were recorded and it causes over 12,000 deaths
annually. Worldwide, 1.38 million women were diag­
nosed with breast cancer in 2008. Until 1999 it was the
primary cause of cancer death in women (ONS 2010b).
Risk factors of breast cancer (van den Brandt
et al. 2000; Dixon 2001; Clavel-Chapelon 2002;
Megdal et al. 2005)
1. Gender – predominantly female.
2. Age – increases with age.
3. Hormonal – uninterrupted menstrual cycles, early
menarche/late menopause.
4. Reproduction – no children or delay, and lack of
breastfeeding.
5. Exogenous hormones – contraceptive pill/hormone
replacement therapy.
6. Family or personal history of breast cancer.
7. Other – postmenopausal obesity; lack of physical
activity; excess alcohol consumption; exposure to
ionising radiation; fatty diet; working long night
shifts; and higher socioeconomic status.
Initial diagnosis is made by mammography and
ultrasound scan followed by needle aspiration or biopsy
to establish the extent and stage of the disease, and
its hormonal (oestrogen and progesterone) status. There
are different types of breast cancer whose names relate
to the position of the lesion, for example invasive ductal
breast cancer, invasive lobular breast cancer or two very
early types called ductal carcinoma in situ (DCIS) and
lobular carcinoma in situ (LCIS). There are four stages
(Table 27.1) of breast cancer with stages I–III being poten­
tially curable.
The majority of patients will undergo surgery to remove
the cancer, although management depends on the stage of
the disease. Many women choose breast-sparing surgery
(e.g. wide local excision, lumpectomy) which removes the
breast lump and surrounding tissue. Scars are normally
small and cosmetic appearance of the breast is good, with
obvious psychological benefit. If the cancer is large or
below the nipple a mastectomy is more appropriate. For
some patients primary breast reconstruction is achieved at
the same time as mastectomy, although it is usual to delay
this until all oncology treatment has been completed.
During surgery, axillary lymph nodes are excised to assess
whether the cancer has spread beyond the breast. Histori­
cally, all the axillary lymph nodes were removed; however,
newer techniques of sampling lymph nodes and sentinel
node biopsy are now undertaken, which may reduce the
future incidence of lymphoedema (Mansel et al. 2006).
623
 Tidy’s physiotherapy
Table 27.1  Stages of breast cancer
Stage I Tumour up to 2 cm
No lymph nodes affected
No evidence of spread beyond the breast
Stage II Tumour between 2 cm and 5 cm and/or:
lymph nodes in armpit affected
no evidence of spread beyond the armpit
Stage III Tumour more than 5 cm
Lymph nodes in armpit affected
No evidence of spread beyond the armpit
Stage IV Tumour of any size
Lymph nodes in armpit often affected
Cancer has spread to other parts of the body
Adjuvant therapies
Radiotherapy is frequently used, particularly after breast-
sparing operations. Its main aim is to irradiate any remain­
ing cancer cells.
Chemotherapy is mainly used for pre-menopausal women
and when the cancer has spread to the axillary lymph
nodes, or may be given as neo-adjuvant therapy to shrink
the tumour facilitating more conservative surgery. Women
who have oestrogen-sensitive tumours also receive some
form of hormonal therapy, for example Tamoxifen or
Arimidex, to block the cancer-promoting effect of oestro­
gen. Ongoing trials aim to establish the best regimes and
therapies for pre- and postmenopausal women (Wishart
et al. 2002; NICE 2009).
Physiotherapy
The physiotherapeutic approach to problem solving linked
with an anatomical and physiological knowledge of the
shoulder complex plays an important role in the rehabili­
tation of breast cancer patients. Physiotherapists promote
independence and a return to normal activities, ultimately
improving quality of life. Ward exercise groups can work
well postoperatively with patients offering peer support.
Pre-operative care
• Assessment of any existing musculoskeletal shoulder
or neck problems that may affect postoperative
outcomes.
• Identification of potential risk factors for reduced
mobility or lymphoedema.
• Information and advice, including a leaflet on
postoperative exercise.
• Advice and strategies to reduce the occurrence of
lymphoedema. Ideally, circumferential measurements
should be taken as a baseline recording.
624
Postoperative care
Most patients have a drain for 2–5 days, although patients
undergoing sentinel node biopsy and wide local incision
may not. Physiotherapists must be aware of the psycho­
logical impact of a cancer diagnosis and altered body
image that can occur with the loss of a breast.
• Post-operative exercise – daily general upper limb
mobility exercises should be encouraged. Specific
shoulders exercises are taught to prevent stiffness.
Limiting shoulder movements below shoulder level
for the first week postoperatively may result in a
lower incidence of lymphoedema (Todd et al. 2008).
An active programme of exercise and physiotherapy
in the subsequent post-operative period indicates a
greater recovery of shoulder mobility (Schultz et al.
1997; Clodius 2001; Box et al. 2002; Lacomba et al.
2010). Patients require good shoulder mobility to
facilitate radiotherapy positioning. Post-radiotherapy
patients should be encouraged to continue their
shoulder mobility exercises as treatment can cause
delayed-onset stiffness.
Pain
Postoperative pain is normally managed with medication.
However, some patients suffer chronic pain which may be
complex owing to the biomechanical, behavioural, emo­
tional and sociocultural influences. TENS, acupuncture,
muscle imbalance treatment, soft-tissue and joint mobili­
sations, relaxation techniques and alternative or cognitive
behaviour therapies can help.
Prevention of lymphoedema
(see lymphoedema section)
Patients are encouraged to moisturise the arm and breast
area daily with emollient cream and avoid invasive medical
interventions such as venepuncture or blood pressure
measurement on the affected limb. Normal shoulder
mobility and maintaining optimum BMI are also encour­
aged. Some lymphoedema clinics hold breast cancer pre­
vention group sessions for patients undergoing breast
cancer surgery and any axillary intervention.
Cording/axillary web syndrome
Tender, cord-like structures, thought to be a result of lym­
phangitis or lymphatic thrombosis, may arise from the
chest wall to the axilla, sometimes extending down the
arm itself. These cords restrict movement and cause sig­
nificant pain. Gentle soft tissue massage and passive and
active physiological movements initiate dispersion.
Scarring
Surgical scars may become adhered to underlying
structures, for example fascia, resulting in tightness and
discomfort in the axilla and chest wall. Patients are
 Physiotherapy in women’s health
encouraged to massage scars once healed to improve tissue
pliability.
Postural advice
Removal of breast tissue causes a weight imbalance and
may result in shoulder protraction. If not corrected, the
pectoral muscles will shorten and tighten leading to
muscle imbalance and pain.
Numbness
During axillary surgery cutaneous nerves are incised result­
ing in sensory loss in axilla, lateral chest wall and upper
arm. It is not uncommon for patients to experience pain
and paraesthesia as sensation recovers.
Return to function
Patients are encouraged to lead an active and normal life
after having breast surgery. Care is always needed to
prevent lymphoedema but patients should not be discour­
aged from activities of daily living that could improve
quality of life.
LYMPHOEDEMA
Definition
Lymphoedema is a chronic and progressive swelling
caused by a low output failure of the lymphatic system,
resulting in the development of a high-protein oedema in
the tissues (Földi et al. 2003).
Lymphoedema is a form of chronic oedema, a persistent
swelling owing to excess accumulation of fluid in the
tissues (BLS 2001). It can affect people of all ages and
occurs in limb/limbs, head and neck, trunk or genital area,
but is more frequently seen in a unilateral upper limb after
breast cancer, or bilateral lower limbs. Lymphoedema may
not become apparent for some time after initial trauma or
surgery and patients have a lifetime risk of developing it.
Lymphoedema affects individuals physically, psychologi­
cally and socially and has a significant impact on quality
of life and ability to undertake normal activities.
Other factors including chronic venous insufficiency,
recurrent cellulitis, inflammation, dependency or obesity
can result in chronic oedema. Provided there are no indi­
cations for medical intervention, a combination of physi­
cal therapies may be very beneficial.
Classification of lymphoedema
Primary lymphoedema is a result of either congenital abnor­
malities or the absence of lymph tissue. It usually presents
Chapter 27
at puberty, rarely soon after birth and, although less
common than secondary lymphoedema, it is often more
extreme with disability being present for much of a
patient’s life (Sitzia et al. 1998). It may be congenital
and some forms of genetic mutation result in known
subgroups such as Milroy disease and lymphoedema dis­
tichiasis. A new system of classification is being developed
(Connell et al. 2010).
Secondary lymphoedema occurs owing to anatomical
obliteration of part of the lymphatic system as a result of
an extrinsic process (e.g. surgery or repeated infections) or
as a consequence of functional deficiency (e.g. paralysis)
(ISL 2003).
In the Western world, cancer or its treatment is a
common cause of secondary lymphoedema. Surgical re­­
moval of part of the lymphatic system, or fibrotic changes
subsequent to surgery or radiotherapy, result in a partial
obstruction in lymphatic drainage and the development
of lymphoedema in the affected limb and associated part
of the trunk. Onset can occur many years after the initial
cancer treatment (Stanton et al. 1996).
Prevalence and incidence  
of cancer-related lymphoedema
Evidence suggests a crude prevalence for chronic oedema
of 1.3 per 1000 (Moffat et al. 2003). Incidence for people
with breast cancer-related lymphoedema is estimated at
around 25% of the population receiving treatment (Pain
and Purushotham 2000). Evolving surgical techniques,
such as sentinel lymph node biopsy, may ultimately
reduce the incidence in patients not requiring full axillary
clearance; however, there is currently little information to
substantiate a population reduction (Armer 2005). Evi­
dence around the incidence of lower limb and midline
lymphoedema is limited although there are indications
that risk of lymphoedema is at least equal to that for breast
cancer patients (Keeley 2000).
The number of people in the UK with a non-cancer-
related lymphoedema may outnumber those with a
cancer-related lymphoedema by a ratio of 3 : 1 (Moffat
et al. 2003). The prevalence of lymphoedema increases
with age (5.4 per 1000 over the age of 65 years).
Onset and progression
Onset of lymphoedema is often marked by intermittent
swelling and paraesthesia (Piller 1999). Initially, the
oedema is soft and pitting and reduces on elevation
(Keeley 2000). With time and recurrent skin infections,
fibrotic changes occur both in the skin and subcutis,
with a progressive swelling and distortion of shape. Skin
and tissues become thickened with enhanced skin folds
and increased adiposity, and the swelling becomes largely
non-pitting. Limb size increases and is sometimes ac­­
companied by a distortion in shape. Movement becomes
625
 Tidy’s physiotherapy
restricted as the limb becomes increasingly heavy and
uncomfortable.
Lymphoedema sufferers are predisposed to recurrent
acute infections, often referred to as cellulitis (Browse
et al. 2003). Signs and symptoms of these apparent skin
infections include acute pain, swelling, anorexia, fevers,
vomiting and rigors.
The psychosocial impact of living with lymphoedema
can be profound, resulting in embarrassment, loss of
self-esteem and increased feelings of anxiety and depres­
sion. Patients also experience impaired physical mobility
and pain (Tobin et al. 1993; Woods et al. 1995; Williams
et al. 2004).
Although no curative treatment is available, a combi­
nation of physical therapies, delivered by a specialist
clinician, is used to control and reduce the complications
associated with lymphoedema. Ongoing reviews are
usually required.
Physiotherapy
Treatment is based around four key areas (Földi et al.
2003; Jenns 2000).
• Skin care – daily washing and application of
emollient cream, and provision of information and
advice on skin care to minimise the risk of cellulitis.
Advice includes protection of the skin from cuts,
insect bites and burns (e.g. when gardening, sewing
or sunbathing). Whenever possible, medical
interventions, such as venepuncture or taking blood
pressure, should be undertaken on the unaffected
side. In lower limb lymphoedema, identification
and treatment of fungal infections is paramount.
• Compression garments/multilayer lymphoedema
bandaging (MLLB). MLLB is used in combination
with lymphatic massage to reverse complications,
such as severe swelling or distorted limb shape, prior
to the introduction of compression garments (Badger
et al. 2000). Although bandaging is used in the
initial treatment of some patients with complex
needs, compression garments are a mainstay of
treatment in many patients to limit and control
swelling. In breast cancer, a garment such as a glove,
sleeve or combined glove and sleeve may be used
depending on the extent of swelling. Garments are
usually worn during the day, especially for exercise
and when working. Pneumatic compression therapy
(e.g. Flowtron) is a method of treatment traditionally
used, but there is concern that continued use may
increase the risk of midline swelling (Boris and
Lasinski 1989; Casley-Smith and Casley-Smith
1997). Newer pneumatic therapy machines based on
the principle of manual lymphatic drainage massage
are now available and are reducing the risks.
• Dynamic exercise is beneficial, as lymphatic drainage
is enhanced by the muscle pump effect, particularly
626
when a compression garment is worn. Gentle
stretching exercises also help to maintain or improve
range of movement and to facilitate good posture
(Harris et al. 2001). Excessive exercise can increase
the lymphatic load and result in further swelling, so
patients are warned to introduce any new activity
gradually and with caution.
• Manual lymphatic drainage (MLD) is characterised by
the pressure and sequence of the technique, designed
to stimulate drainage through the functioning
lymphatics. This is usually the only method of care
available to treat midline oedema (i.e. face, genitals
and trunk). Simple lymphatic drainage (SLD)
(Williams et al. 2002) is taught to patients.
PSYCHOSEXUAL ISSUES
Throughout this chapter contributors have described a
range of life stages, conditions, dysfunctions, pathologies
and interventions which have not only a physical, but also
a psychological, impact on the women concerned. Many
also affect the psychological and emotional aspect of sex
– i.e. are psychosexual concerns – of which the physiother­
apist should be aware.
Pregnancy and childbirth
Although there is no evidence that sex during pregnancy
could be harmful (NICE 2008b), sexual activity may
decrease during pregnancy (Pauleta et al. 2010; Serati
et al. 2010) and this can continue postnatally for
various reasons, the most common being pain (Abdool
et al 2009).
Menopause
Vaginal dryness may result in painful intercourse and
women of menopausal age may also report sexual dys­
function associated with altered libido, arousal and other
aspects of sexuality (NIH 2005).
Gynaecological surgery
Although women are advised that sexual intercourse can
normally be resumed 4–6 weeks after surgery (RCOG
2010), some report sexual problems which might relate to
loss of desire, lubrication, sensitivity, elasticity, capacity
or pain, and which are possibly more prevalent in
women who have undergone surgery for malignancy
(Aerts et al. 2009).
Breast cancer
Women may suffer poorer body image, anxiety/depression,
side effects, such as vaginal irritation and lowered libido,
 Physiotherapy in women’s health Chapter 27

related to their treatment, affecting their sexuality

(Sheppard and Ely 2008). Weblinks

Association of Chartered Physiotherapists in Women’s

Urinary incontinence
One third of women who experience urinary inconti­
nence may leak with intercourse, which has a significant
impact on their reported quality of life (Pons and
Clota 2008).
The above list is by no means exhaustive.
The physiotherapist is one of the few professionals
who may include a vaginal examination as part of her/
his assessment. This is a very intimate procedure and
a time of self-awareness for the patient, which should
be approached with sensitivity and care. It may be the
occasion when past feelings come to light, for example
previous sexual abuse. The physiotherapist may be the
first person with whom the woman shares some of her
concerns. Psychosexual counselling may not be a physi­
otherapy core skill, but clinicians in women’s health
should know what services are available locally and how
to access them. In addition, they may wish to access
postgraduate training to enhance their skill set.
Health (ACPWH): http://acpwh.csp.org.uk/
International Organization of Physical Therapists in
Women’s Health (IOPTWH): www.ioptwh.org
Bladder and Bowel Foundation:
www.bladderandbowelfoundation.org
Chartered Physiotherapists Promoting Continence:
www.cppc.org.uk
International Continence Society: www.icsoffice.org
International Urogynecological Association: www.iuga.org
The British Menopause Society: www.thebms.org.uk
Menopause Matters: www.menopausematters.co.uk
Cancer Research UK: www.cancerresearchuk.org
Breast Cancer Care and Research Fund:
www.breastcancercare.org
Institute of Psychosexual Medicine: www.ipm.org.uk

FURTHER READING

Physiotherapy in women’s
health
Mantle, J., Haslam, J., Barton, S. (Eds.),
2004. Physiotherapy in Obstetrics
and Gynaecology, second ed.
Butterworth-Heinemann, Oxford.
Irion, J.M., Irion, G.L. (Eds.), 2010.
Women’s Health in Physical
Therapy. Lippincott, Williams &
Wilkins, Baltimore.
Sapsford, R., Bullock-Saxton, J.,
Markwell, S., 1998. Women’s Health:
A Textbook for Physiotherapists.
WB Saunders, London.
Pregnancy and childbirth
Fraser, D., Cooper, M. (Eds.), 2010.
Myles Textbook for Midwives,
fifteenth ed. Churchill Livingstone,
Edinburgh.
Macdonald, S., Magill-Cuerden, J.
(Eds.), 2011. Mayes Midwifery: A
Textbook for Midwives, fourteenth
ed. Baillière Tindall, London.
Antenatal classes, advice
and exercises
Brayshaw, E., 2003. Exercises for
Pregnancy and Childbirth: A Guide
for Educators. Books for Midwives,
Oxford.
Nolan, M.L., Foster, J., 2004. Birth and
Parenting Skills: New Directions in
Antenatal Education. Churchill
Livingstone, Edinburgh.
Schott, J., Priest, J., 2002. Leading
Antenatal Classes: A Practical
Guide. Books for Midwives
Press, Oxford.
Pelvic floor muscle dysfunction
and rehabilitation
Bø, K., Berghmans, B., Mørkved, S.,
et al. (Eds.), 2007. Evidence-based
Physical Therapy for the Pelvic
Floor. Elsevier, Edinburgh.
Haslam, J., Laycock, J. (Eds.), 2008.
Therapeutic Management of
Incontinence and Pelvic Pain,
second ed. Springer-Verlag,
London.
Breast cancer and lymphoedema
Mortimer, P., Todd, J., 2007.
Lymphoedema: Advice on Self-
management and Treatment, third
ed. Beaconsfield Publishers Ltd,
Beaconsfield.
Psychosexual issues
Schachter, C.L., Stalker, C.A., Teram, E.,
et al., 2009. Handbook on Sensitive
Practice for Health Care
Practitioners: Lessons from Adult
Survivors of Childhood Sexual
Abuse. Public Health Agency of
Canada, Ottawa.

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635
 Dedication

I dedicate this book to the memory of Krish Gooranah, Richard Butcher and Graham Dunn. On behalf of my colleagues
at the University of Salford it was our pleasure to have known and taught these fine young men all too briefly; our
sadness at their passing is profound.

xv
Tidy’s Physiotherapy

Edited by

Stuart B. Porter PhD, BSc (Hons), GradDipPhys, MCSP, FHEA, SRP, CertMHS
Lecturer, University of Salford, Manchester, UK
External Examiner, University of East London, UK
External Examiner, University of Bradford, UK

Edinburgh  London  New York  Oxford  Philadelphia  St Louis  Sydney  Toronto  2013
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 Contributors
Helen Alsop BSc (Hons), MCSP, SRP
Private Practicioner, Sprint Physiotherapy Ltd., London, UK
Andrew Bannan MSc, BSc (Hons), HND, CertEd,
MCSP, MHCPC
Lecturer in Physiotherapy, University of Essex; Clinical
Specialist Physiotherapist, Bury Physiotherapy; First Team
Physiotherapist, Bury St Edmunds Rugby Club; School of
Health and Human Sciences, University of Essex,
Colchester, UK
Gill Brook MCSP, MSc
Women’s Health Physiotherapist, Bradford Teaching Hospitals
NHS Foundation Trust; Honorary Lecturer, University of
Bradford; Secretary of the International Organization of
Physical Therapists in Women’s Health, Otley, West
Yorkshire, UK
Tamsin Brooks BSc (Hons), MCSP, HPC
Women’s Health Physiotherapist, Private Practicioner,
Bakewell Physiotherapy Clinic, Bakewell, UK
Helen Carruthers MSc, BSc (Hons), CertHE,
MCSP, PGCert
Lecturer in Physiotherapy, Admissions Officer Part-time
Programme, University of Salford, Salford, UK
Catherine Carus MSc, GradDipPhys, PGCHEP, MCSP
Physiotherapy Lecturer, Division of Allied Health Professions,
University of Bradford, School of Health Studies,
Bradford, UK
Alan Chamberlain MA, PG DPE, MCSP, RGN
Fellow of the Higher Education Academy, Senior Lecturer in
Physiotherapy, Programme Lead MSc in Advanced Practice in
Physiotherapy and MSc Physiotherapy, Faculty of Health and
Wellbeing, University of Cumbria, Carlisle/Lancaster, UK
Alison Chambers EdD, MEd, MCSP, FHEA
Dean of Academic Development and Employability,
University of Central Lancashire, Preston, UK
Ambreen Chohan PhD, MPhil, BEng (Hons)
RA Clinical Biomechanics, Allied Health Professions, School of
Sports, Tourism and the Outdoors, University of Central
Lancashire, Preston, UK
Lynn Clouder GradDipPhys, BSc (Hons), MA, PhD,
MCSP, FHEA
NTF Director of the Centre for Excellence in Learning
Enhancement (CELE), Professor, Faculty of Health and Life
Sciences, Coventry University, Coventry, UK
Yvonne Coldron PhD, MSc, MCSP, MMACP
Clinical Specialist Physiotherapist, Croydon Healthcare
Services NHS Trust, Croydon, UK
Louise Connell PhD, MCSP
Research Therapist, Division of Physiotherapy Education,
University of Nottingham, Nottingham, UK
Lindsey Dugdill BA, MA, MPhil, PhD
Professor of Public Health, College of Health and Social Care,
University of Salford, Salford, UK
Anne Dyson MCSP, SRP
Physiotherapy Manager, Liverpool Heart and Chest Hospital
NHS Foundation Trust, Liverpool, UK
Stephanie Enright PhD, MPhil, MSc, MCSP,
SRP, PGCertHE
Wales College of Medicine, Biology, Life and Health Sciences,
Cardiff University, Cardiff, UK
Renuka Erande MSc, BSc, CSP
Stroke Research Practitioner, University College London
Hospitals, NHS Foundation Trust, Thames Stroke Research
Network, London, UK
Sally French
Freelance Researcher and Writer; Associate Lecturer at the
Open University, UK
Lynne Gaskell M (Res) GradDipPhys, MCSP
Lecturer in Physiotherapy, Directorate of Sport, Exercise and
Physiotherapy, School of Health, Sport and Rehabilitation
Sciences, University of Salford, Salford, UK
Janette Grey GradDipPhys, CertEd HE/FE, MSc, MCSP,
HPC registered, FHEA
Professional Lead for Physiotherapy, University of Central
Lancashire, Preston, Lancashire, UK
vii
 Contributors
Rob Grieve PhD, MSc, MCSP
Senior Lecturer in Physiotherapy, Department of Allied Health
Professions, Faculty of Health and Life Sciences, University of
the West of England, Bristol, UK
Carolyn A. Hale GradAssocPhys, MSc, HCPC
Chartered Physiotherapist, Clinical Specialist, Pace
Rehabilitation, Cheadle, Cheshire, UK
Ruth Hawkes FCSP
Women’s Health Physiotherapist, Choir School Physiotherapy,
Lincoln, UK
Lee Herrington PhD, MCSP
Senior Lecturer in Sports Rehabilitation, Programme Leader
MSc Sports Injury Rehabilitation, Directorate of Sport,
Exercise and Physiotherapy, School of Health, Sport and
Rehabilitation Sciences, University of Salford, Salford, UK
Linda Hollingworth
Senior Lecturer, Directorate of Sport, Exercise and
Physiotherapy, School of Health Sciences, University of
Salford, Salford, UK
Lester Jones MScMed (PM), BAppSc (Hons), BBSc,
GradDipBehavStdsHlthCare
Lecturer, Department of Physiotherapy, Faculty of Health
Sciences, La Trobe University, Melbourne, Australia
Mandy Jones PhD, MSc, MCSP, SRP
Course Director, Physiotherapy School of Health Sciences and
Social Care, Brunel University, London, UK
Swati Kale MSc, BSc, PGCHEP, MCSP
Lecturer in Physiotherapy, Admissions Officer for BSc
Physiotherapy and MSc Physiotherapy, University of East
Anglia, Norwich, UK
Judith Lee MCSP
Clinical Specialist Women’s Health Physiotherapist,
Nottingham University Hospitals NHS Trust, Nottingham, UK
Melanie Lewis MCSP
Lead Macmillan Lymphoedema Physiotherapy Specialist,
Singleton Hospital, Swansea, UK
Monika Lohkamp PhD, MSc, MCSP, FHEA
Lecturer in Sport Rehabilitation, Department of Sport, Health
and Exercise Science, University of Hull, Hull, UK
Duncan Mason BSc (Hons), SRP
Lecturer in Physiotherapy, Directorate of Sport, Exercise and
Physiotherapy, School of Health, Sport and Rehabilitation
Sciences, University of Salford, Salford, UK; Director of
Athlete Matters, Manchester Endurance Physiotherapist UK
Athletics, UK
Paula McCandless MSc, MCSP, SRP, FHEA
Senior Lecturer in Physiotherapy (Neurology), School of Sport,
Tourism and the Outdoors, University of Central Lancashire,
Preston, UK
viii
Lorimer Moseley PhD, BAppSc (Hons), FACP
Professor of Clinical Neurosciences and Chair in
Physiotherapy, The Sansom Institute for Health Research,
University of South Australia, Adelaide, Australia; Senior
Research Fellow, Neuroscience Research Australia, Sydney,
Australia
Wendy Munro MSc, PGCert HEPR, MCSP
Lecturer in Physiotherapy, Programme Leader Part-time
Route, Directorate of Sport, Exercise and Physiotherapy,
School of Health, Sport and Rehabilitation Sciences,
University of Salford, Salford, UK
Hilary Pape MSc, BSc (Hons), DPodM PCAP
Physiotherapy Lecturer, Division of Allied Health Professions,
University of Bradford, Bradford, UK
Sue Pieri-Davies MCSP, MSc, PGCILTH
Consultant AHP and Lead Clinician – Ventilation Services;
Lecturer for Cardiff and Edge Hill Universities, NWRSIC
Southport District General Hospital, Southport, UK
Sarah Prenton BSc (Hons), PGCert HEPR, MCSP
Lecturer in Physiotherapy, Directorate of Sport, Exercise and
Physiotherapy, School of Health Sciences, University of
Salford, Salford, UK
Ann Price MSc, MCSP, DipTP, Cert Ed
Advanced Practitioner in Arthroplasty, Wrightington Hospital,
Lancashire, UK
Bhanu Ramaswamy MCSP, MSc (First Contact Care),
PracCert Non-medical Prescribing, PGCert (Neurological
Physiotherapy), GradDipPhys, SRP
Independent Physiotherapy Consultant, Sheffield; Honorary
Visiting Fellow at Sheffield Hallam University, Sheffield, UK
Gillian Rawlinson
Senior Lecturer, University of Central Lancashire, Preston,
Lancashire, UK
Melanie Reardon MSc GradDipPhys, MCSP,
SRP, CertMHS
Senior Physiotherapist, Southport and Ormskikr NHS Trust,
Southport, UK
Jim Richards PhD, MSc, BEng (Hons)
Professor of Biomechanics and Research Lead for Allied
Health Professions, School of Sports, Tourism and the
Outdoors, University of Central Lancashire, Preston, UK
Alec Rickard BSc (Hons), PGCert LTHE, MCSP, FHEA
Lecturer and Admissions Tutor, Physiotherapy, School of
Health Professions, Faculty of Health, University of Plymouth
Peninsula Allied Health Centre, Plymouth, UK
Sushma Sanghvi MSc, MSc (Ayu), MCSP, MA
Freelance Lecturer and Consultant Physiotherapist,
The Sherwood Clinic, Harrow, UK

Fiona M. Schreuder MSc, BAppSc, PGDip LTHE, MCSP,
HPC registered
Senior Lecturer, Physiotherapy Division, Department of Allied
Health Professions and Midwifery, School of Health and Social
Work, University of Hertfordshire, Hatfield, UK
Ceri Sedgley
Professional Adviser, Chartered Society of Physiotherapy,
London, UK
Katie Small PhD, BSc (Hons), GSR
Senior Lecturer in Sports Therapy, Quality Group Sport and
Physical Activity, Faculty of Health and Well-being, University
of Cumbria, Carlisle, UK
Christine Smith MSc, GradDipPhys, Cert Ed
Director, School of Health, Sport and Rehabilitation Sciences,
Senior Lecturer in Physiotherapy, University of Salford,
Salford, UK
Nicholas T.L. Southorn BSc (Hons), MSc, MCSP
Physiotherapy Pain Specialist, PhD (Medicine) Student, Pain
Management Solutions Ltd, Nottingham, UK
John Swain BSc (Hons), MSc, PhD, PGCE
Professor of Disability and Inclusion, Research and Enterprise
Health, Community and Education Studies, Northumbria
University, Benton, Newcastle-upon-Tyne, UK
Jacquelyne Todd MCSP, PhD
Physiotherapy Consultant in Lymphoedema, Wharfedale
Hospital, Otley, West Yorkshire, UK
Contributors
Kathleen Vits MCSP, MSc
Women’s Health Physiotherapist Urogynaecology
Department, Princess Anne Hospital, Southampton, UK
Anita Watson BSc (Hons), MCSP, SRP
Lecturer in Physiotherapy, School of Health, Sport and
Rehabilitation Sciences, University of Salford, Salford, UK
Tim Watson PhD, BSc, MCSP
Professor, Department of Allied Health Professions and
Midwifery, School of Health and Social Work,
University of Hertfordshire, Hatfield, UK
Joan M. Watt MA, MCSP, MSMA
Hon President CPMaSTT; President Sports Massage
Association; Hon Medical Advisor Scottish Commonwealth
Games; Lead Physiotherapist British Shooting; Head
Physiotherapist to GB Athletics 1984 to 1996.
Liz Whitney RGN, RM, BSc (Hons), Combined Health
Studies, MSc Midwifery, PGDip HE
Midwifery Lecturer, University of Bradford, Bradford, UK
Jill Wickham MSc, MCSP, FHEA
Senior Lecturer in Physiotherapy; Co-ordinator for CPD
and Lifelong Learning, Faculty of Health and Life Science,
York St John University, York, UK
Kelly L. Youd BSc (Hons), MCSP, SRP
Physiotherapy Clinical Lead – Critical Care, Liverpool Heart
and Chest Hospital NHS Foundation Trust, Liverpool, UK
ix
 Preface

Tidy’s Physiotherapy returns for its fifteenth edition and for a third time I have been entrusted with the task of editing it.
Once again in this new edition, experts from a wide range of clinical and academic backgrounds have produced chapters
that give physiotherapy students a clearly laid out reference guide, whilst at the same time encouraging them to problem-
solve and facilitate their learning. With my team of authors, we have maintained the strong core that has become the
hallmark of this textbook and added some new chapters, for example, on reflection, leadership, neurodynamics and
acupuncture. Each author brings their own professional experience and flavour to the chapters and the final result is a
textbook which is palatable and accessible to students and practitioners alike.
As usual my thanks to all my students who teach us so very much.
I would like to give specific thanks to Rita Demetriou-Swanwick, Veronika Watkins and Clive Hewat at Elsevier for
their support. The following people have been an invaluable source of opinions and comments: Debra Dunlop, Angie
Fairhurst, Natalie Ingham, Kirsty Smith, Basharat Kahn, Evaggelia Moriatis, Daniel Richards, Rebecca Borsbey, Andrew
Gerling, Charlotte Kelly, Natasha Barrett, Rachel Sellens, Andrew Lockhart, Laura Jane Cowdell, Louis Platt, Sante Saleh,
Paul Cieplak, Martyn Matthews, Suzanne (Binns) McCollum, Gemma Hepburn, Stacey Arthern, Paul Wike, Sviatlana
Birukova, Nina Dean, Gemma Dickinson, Jennifer Littler, Sarah Willians, Adam Newall, Rita Ijeomah, Andrew Lee, Alisha
Alford, Darragh Sheehy, Adrianna Hynowska, Nicola deJong, Alisha Alford, Rachel Squibbs, Daniel Rix and Alex Long.
For the Southeast Asia edition I am indebted to Kush Yadav BPT, MSc in advancing physiotherapy, Gurpreet Singh
BPT MSc in advancing physiotherapy and Suhas Deshmukh BPY MSc in advancing physiotherapy.
Finally, my wife whose love and support spur me on, and my daughters, who may have outgrown my lap but will
never outgrow my heart.

Dr Stuart B Porter
PhD, BSc (Hons), GradDipPhys, MCSP, FHEA, SRP, CertMHS
Lecturer in Physiotherapy
Admissions Officer, Full Time Programme
Admissions Officer MSc, Advancing Physiotherapy
Level 1 Manager, Full Time Programme
University of Salford, Manchester
External Examiner, University of Bradford
External Examiner, University of East London

xi
 Student’s
Testimonial

If you want something done – do it yourself. If you want something done well – ask Dr Stuart Porter.
As Tidy’s fresh-faced new editor all those years ago, Dr Porter dragged a tired, limping beast of a textbook off the shelf
and not only into the twentieth century but also to the top of the best-selling physiotherapy textbook list. To take on
such a Herculean job may also be seen as a thankless Sisyphean task. Nonetheless, Dr Porter has achieved that which
would take many a lifetime: an engaging, highly useable, professional textbook that manages to straddle several profes-
sions, while still being pertinent and user-friendly to all.
The 15th edition continues to act as a transparent and readable reference book for physiotherapy students who often
require an anchor in the stormy waters of undergraduate study. Included in this edition are topics as diverse as neuro-
dynamics, biomechanics, pain and pharmacology – all of which are relevant to students from a wide variety of profes-
sional backgrounds.
No success is achieved single-handedly and this edition is no exception – teeming, as it does, with a plethora of
professionals; indeed, it is their knowledge and their desire to impart this to others that ensures this edition will excel.

Katherine E. Crook MA PGDE BA

Bury, 2012

xiii

Page numbers followed by ‘f ’ indicate
figures, ‘t’ indicate tables, and ‘b’
indicate boxes.
A
Aδ fibres, 382, 382t
ABC UK (Activities-Specific Balance
Confidence Score), 470
abdominal muscles, female, 606–607
anatomy/physiology, 606–607
in pregnancy, 609
re-education, 614–615
abduction
hip joint, 239
prosthesis, transfemoral amputee,
469
shoulder joint, 232, 321t
exercises, 232, 286f
see also FABER test
abductors, hip, assessment, 238–239,
238f
abscess, lung, 117–118
acceleration
angular see angular acceleration
gravity and, 345
linear see linear acceleration
Newton’s second law and, 344
accessible communication, 195–196
accessory movements
assessment, 212
ankle joint, 249–250
cervical spine, 229
hip joint, 240
knee joint, 243, 245–246
lumbar spine, 222–223
shoulder joint, 233
with femoral shaft fractures, loss,
503, 519
in soft tissue injury rehabilitation,
212–213
Index
accessory respiratory muscles, 129
Accuhaler (Disk), 99
ACE (angiotensin-converting enzyme)
inhibitors, 58
acetaminophen, 60–61, 65
Achilles tendon reflex, 220, 221f
Achilles tendonitis, frictions in, 491
aciclovir, 63
acoustic streaming, ultrasound, 437
acromioclavicular joint assessment,
233–234
action
reflection before (reflection on
future), 73, 79f
reflection during/in, 72b, 73, 79f
reflection following/on, 72b, 73,
79f
action learning sets, 49–50
action potentials, nerve, 61, 420–421
action–reaction in Newton’s third law,
344–345
active cycle of breathing technique
COPD, 94
thoracic surgery patient, 178
active exercises
assisted, 280
free, 276–278, 281
in acute respiratory distress
syndrome, 116
active insufficiency of muscles, 214
active movements
assessment, 212
ankle joint, 248–249
cervical spine, 226–227
hip joint, 239
knee joint, 249
lumbar spine, 216–217
shoulder joint, 231–233
active muscle imbalance, 306
active phase of breathing cycle,
130–131
Index
activities (activity), neurological
patients, 584
definition in International
Classification of
Functioning, 583
as outcome measure, 585t
activities of daily living
in cardiac rehabilitation, 162
impairments impacting on,
543–544
see also exercise
Activities-Specific Balance Confidence
Score (ABC UK), 470
acupressure, 488–489
acupuncture, 403–415
antenatal, 615
clinical implications, 410–411
history, 403–404
meridian points see meridian points
acupuncture TENS, 423
acute respiratory distress syndrome
(ARDS), 115–116
risk with fractures, 499
acyclovir, 63
adduction
hip joint, 236, 239
scapulothoracic joint, 321t
adenocarcinoma, lung, 120t
adenosine, 63
adherence (compliance) with exercise
prescription, 300–301
adhesions
intra-/periarticular, fractures leading
to, 500–501, 522
soft tissue, prevention, 266–267
adjunct analgesia drugs, 63
adjuvant therapies in breast cancer, 624
adolescents
cystic fibrosis, clinical features, 107
resistance training, 280
adrenaline, 63
637
 Index

advance pressure modes of ventilation,
129–133
advice see education
aerobic exercise
in cardiac rehabilitation,
adaptations at
submaximal level of,
153–154
in pregnancy, 617
age
of condition, determining, 210–211
fracture union and, 499
heart rate maximum in exercise
training and, 155
soft tissue healing and, 262
see also adolescents; children;
infants; older people
ageing, 539–540
AGILE (clinical interest group of
Chartered Society of
Physiotherapy), 539, 545,
545b
fall prevention, 551
agonist, 62
aims in goal-setting (neurological
patient), 586, 586t
air pollution and chronic bronchitis,
85
airflow
resistance, 132–133
disorders of see obstructive
pulmonary disease
in spontaneous ventilation,
130–131
airway disease see obstructive
pulmonary disease;
respiratory disease;
restrictive pulmonary
disease
airway pressure, positive see positive
airways pressure
airway pressure release ventilation, 137
akinesia, Parkinson’s, 541–542
alendronate, 63
alfentanil, 63
algodystrophy see complex regional
pain syndrome
alignment
ankle/foot, 247–248
lumbar spine
deviation, 215–216
normal, 215
shoulder, anterior/posterior/lateral,
231
see also deformities
allergens in asthma, 84, 95–96
avoidance, 101
Allied Health Professions, 43–45
interprofessional education and, 27
allodynia, 385, 385b
alveolar hypoventilation, 133–134,
134t
alveolitis, fibrosing, 117
aminoglycosides, 59
aminophylline, 63
amiodarone, 63–64
amitriptyline, 64
amlodipine, 64
amortisation phase, 295
‘amplitude’ window for electrotherapy,
419
amputation (predominantly lower
limb), 457–474
assessment, 461–462
causes, 457–458
complex/multiple, 471
levels, 458, 458t
outcome measures, 469–470
pain and its relief, 459–460
psychosocial impact, 458–459
role of physiotherapist, 460–461
special considerations, 470–471
stages of physiotherapy, 462–468
Amputee Mobility Predictor (AMP
Pro), 470
amyotrophic lateral sclerosis, 596
anaesthesia, 59–61
epidural see epidural analgesia/
anaesthesia
local anaesthetics, 61
anal disorders, 621
incontinence see faeces
analgesia (in general) see pain
management
analgesic drugs, 59–61, 391, 391b
adjuncts, 63
childbirth, 611
thoracic surgery, 176
anatomy
acupuncture and knowledge of,
406
pelvic, women, 605–608
angina, 58
stable, cardiac rehabilitation,
149
angiotensin-converting enzyme (ACE)
inhibitors, 58
angular acceleration, 340
knee (normal and osteoarthritic)
during walking, 342
angular displacement, 340
knee (normal and osteoarthritic)
during walking, 341
angular power, 361
angular velocity, 340
knee (normal and osteoarthritic)
during walking, 341–342
angular work, 361
ankle (joint), 220–222, 221f, 246–250
angle, 333
assessment, 246–250
femoral shaft fractures, 503
dorsiflexion see dorsiflexion
fractures around, 516
ligaments see ligaments
moments, 358
in gait, 359
motion/movements, 248, 334–335
power during walking, 362
proprioception, 248
replacement, 537
soft tissue injury (incl. sprains),
246, 257b, 261b, 264b,
270b
case study, 386
anorectal disorders see anal disorders;
rectal disorders
antenatal education and classes (incl.
exercise), 614, 617–618
anterior draw test
ankle, 249
knee, 244
modified (Lachman’s test), 211,
245
shoulder, 234
antiarrhythmic (antidysrhythmic)
drugs, 57
antibiotics, 59
respiratory infections
cystic fibrosis, 108
tuberculosis, 119
ventilator-associated pneumonia,
111
anticholinergics, COPD, 92
anticipation (expectation) of pain, 386
antidepressants, tricyclic, 61
antidysrhythmic drugs, 57
anti-epileptic drugs, 61
anti-inflammatory drugs, 58–59, 391
airway inflammation, 58–59
non-steroidal see non-steroidal
anti-inflammatory drugs
anti-inflammatory effects of
acupuncture, 409
antispasmodics in multiple sclerosis,
595
α1-antitrypsin deficiency, 86–87
anus see anal disorders
anxiety and pain, 386
anxiolytics, 59
Any Qualified Provider, 17–18
ape-like posture, Parkinson’s disease,
542
apraxia, 582
aquatic exercises see water-based
exercises
arm see upper limb

638
 Index

arrhythmias (dysrhythmias), drug pathology, 96 back care classes in pregnancy, 617

therapy, 57 physiotherapy, 102–103 back rehabilitation program, 225
arterial blood gases see blood gases asylum seekers, disabled, 188 bacterial infections, antibiotics see
arterial disease, peripheral see ataxia, 580–581 antibiotics
peripheral vascular disease atelectasis, ventilator-associated, 137–138 Baker’s cyst, 242
arthritis (and inflammatory atenolol, 64 balance
arthropathies) athetosis, 580 amputee
degenerative see osteoarthritis athletes see sports assessment, 461t
laser therapy, 448 atmospheric pollution and chronic postoperative, 464
rheumatoid see rheumatoid arthritis bronchitis, 85 neurological patients, as outcome
arthroplasty (joint replacement), atopic (extrinsic) asthma, 95–97 measure, 585t
525–538 ator(o)vastatin, 64 older people, 548–549
lower limb, 531–537 atropine, 64 Parkinson’s disease, 548–549, 554
hip see hip attention case study of management, 556t
knee, 535–537 pain and its effects on, 386, 386b, ball see gym ball; medicine ball; Swiss
upper limb, 525 395 ball
articulations see joints tactile acuity training, 394b ballismus, 581
Asian people, 187–188 attitudinal barriers to disability, 185, ballistic stretching, 282
aspirin, 60, 64 187–188, 192–193 bandages, compression see
stroke, 590 audit, clinical, 15 compression garments
assessment (patient incl. musculoskeletal auditory cues in Parkinson’s patients, barotrauma, ventilator-induced, 138
tissues), 207–251 555t basal ganglia, 548
amputee, 461–462 auditory disturbances, neurological dysfunction (incl. Parkinson’s
in cardiac rehabilitation, exercise conditions with, 582 disease), 540
training prescription, 154 auscultation (breathing sounds) in proprioception, 288
fractures, 506–509 asthma, 97 BCG vaccination, 119
case study, 519–520 COPD, 90 beating, 485–486
general issues, 207–208 cystic fibrosis, 107 beclomethasone, 64
muscle imbalance, 311–317 fibrosing alveolitis, 117 bed, lower limb amputee rehabilitation
neurodynamic, 563–565 pneumonia, 111 in, 464t
neurological patient, 582–584 auto-assisted exercises, 281 behaviour (individual/personal)
Parkinson’s disease, 544–551 autonomic nervous system, 561 disturbances, 582
objective see objective assessment brain injury, 598 brain injury, 599
older people, 544–551 neurological conditions causing health related to, 189
pain see pain disturbances, 582 changes/improvements in, 199
Parkinson’s disease, 544–551 see also parasympathetic nervous ill (unhealthy behaviour), 189,
pitch-side, 376 system; sympathetic 199–200
proprioception see proprioception nervous system in pain measurement, 388
reflection as form of, 71–72 autonomy (personal freedom), 5 professional, codes, 8–9
subjective see subjective assessment patient, 5 behavioural interventions (incl.
thoracic surgery, 177–178 professional, 2, 5 modification/change),
see also specific musculoskeletal avascular necrosis (with fractures), 500 200
structures femoral neck fractures, 514 in urogenital dysfunction, 620
Association of Chartered avoidance see fear–avoidance beliefs see also cognitive-behavioural
Physiotherapists in avulsion fracture, 495 therapy
Cardiac Rehabilitation pelvis, 513 beliefs and their potential impact on
(ACPICR), 152b axillary lymph nodes in breast cancer, pain, 388–389
Association of Chartered 623–624 clinicians, 389b
Physiotherapists in axillary web syndrome (after breast bendroflumethiazide, 64
Women’s Health, 605, surgery), 624 benign multiple sclerosis, 594
605b axoplasmic flow, 563 Bennett’s fracture, 513
asthma, 95–98 benzodiazepines, 59
acute/acute severe attacks, 98 beta2 (β2) agonists
B
aetiology and prevalence, 95–96 asthma, 98, 100–101
clinical features, 96–98 Babinski reflex, 220b COPD, 92
drug therapy, 58–59 back biceps brachii reflex testing, 228
extrinsic/atopic, 95–97 flat, 216 bilevel ventilation, 137
intrinsic/chronic, 95, 98 pain see low back pain bioavailability, 62
medical treatment, 98–102 sway, 216 biochemical tests, pneumonia, 111

639
 Index
biofeedback
anorectal dysfunction, 621
pressure biofeedback device, 294
in urogenital dysfunction, 620
biological factors affecting health, 189
biomechanics, 331–368
pregnancy-related changes in spinal
and pelvic joints,
608–609
respiratory, 130–131
biopsy, bronchial/lung tumour, 120
biopsychosocial assessment
lumbar spine, 223–225
pain patient, 387, 388t
black flags, 389
black people, disabled, 186
discrimination, 187
bladder dysfunction
multiple sclerosis, 595
women, 618–619
see also urinary incontinence
bleeding see haemorrhage; healing and
repair
blood
coughing up see haemoptysis
flow/supply see circulation
blood disorders complicating fractures,
499
blood gases (arterial)
asthma, 97
COPD, 90
cystic fibrosis, 94
respiratory failure, 129
thoracic surgery, preoperative, 171
see also carbon dioxide; oxygen
blood pressure, high (hypertension),
exercise-based cardiac
rehabilitation and, 163
blood tests (previous), records of, 211
see also haematology
blood vessels see vasculature
blue bloaters, 91
blue flags, 389
body
cortical representations, targeting in
pain management, 394
forces acting on, 346–349, 354–359
function see function
moments acting on, 354–359
positioning, see also positioning
segment see segment angle/inclination
body chart, 208–209
body mass index and exercise-based
cardiac rehabilitation, 164
bone
cervical spine anomalies, 229
fracture and its healing see fracture
metastases from lung cancer, 120
pelvic, female anatomy, 605–606
640
bone scans (previous), records of, 211
Borg category ratio, 156t
Borg rating of perceived exertion, 155t
bow-legs (genu varum), 241
bowel problems in multiple sclerosis,
594
see also faeces; gastrointestinal tract
brachioradialis reflex testing, 228
bracing, 503
femoral shaft fracture, 519–521
bradykinesia, 581
Parkinson’s, 541
brain (cerebrum; supraspinal
structures)
in acupuncture, 409
imaging studies, 407–408
anatomy, 588f
haemorrhage see haemorrhage
injury, 597–600
non-traumatic, 597
traumatic, 372–373, 597–600
metastases from lung cancer, 120
pain/nociceptive mechanisms,
382–386
targeting in pain management,
392
proprioception and the, 288
brainstem and proprioception, 288
breast cancer, 623–625
psychosexual issues, 626–627
breath-activated inhalers, 83
breathing
active phase of cycle of, 130–131
with inhalers, technique, 101–102
sleep and, 122
sounds, auscultation see
auscultation
work of, 131, 134–135
see also expiration; inspiration;
ventilation
breathing control (incl. breathing
exercises)
asthma, 103
COPD, 94
thoracic surgery patients, 178
see also thorax, expansion exercises
breathlessness/shortness of breath see
dyspnoea
brief intense TENS, 423
broad ligament in pregnancy, 607
Broca’s area, damage, 582
bronchi
irritations in COPD, decreasing,
91–92
secretions see secretions
tumours, 119–121
bronchiectasis, 103–105, 171
in cystic fibrosis, 106
surgery, 105, 171
bronchitis, chronic, 85–86
emphysema combined with, 86b
bronchodilators (for bronchospasm
control), 58–59
asthma, 58–59, 98
COPD, 92
cystic fibrosis, 108
bronchopneumonia, 111
bronchopulmonary segments, 170f
bronchoscopy (incl. preoperatively) of
tumours, 120, 171
bronchospasm control see
bronchodilators
buddy strapping for finger fractures,
502
bulbar palsy, progressive, 596
buoyancy, 299–300
buprenorphine, 60
burns from ice, 258
bursa, differentiation tests, 214
burst mode TENS, 423–424, 432
C
C fibres, 382, 382t
cadence, 332
Caesarean section, 611
inpatient postnatal physiotherapy
after, 618
calcaneal fracture, 517
calcaneal valgus and varus, 247
calcium antagonists, 58
calf squeeze test, 250
callus formation, 498
cancellous bone healing, 498–499
cancer (malignant tumour)
amputation in, 470
breast see breast cancer
lung, 119
imaging, 171
lymphoedema in see lymphoedema
massage contraindicated, 480
oesophageal, 169, 171
see also metastases
captopril, 64
carbamazepine, 64
carbon dioxide tension, arterial
(PaCO2), in respiratory
failure, 129
type I failure, 121, 133
type II failure, 121, 133–134
carcinoma, lung, types, 120t
cardiac problems see heart
cardiovascular system
conditioning exercises, 160
disease (CVD), COPD-associated
risk, 90
see also heart disease
drugs acting on, 57–58
 Index

in exercise training, physiological Chartered Society of Physiotherapy pneumothorax, 171

adaptations, 153–154 (CSP), 2–3, 6–8, 13–15, preoperative care in thoracic
ventilator-related adverse effects, 43, 47–48 surgery, 177
139 AGILE (clinical interest group) see chronicity of condition, determining,
see also circulation AGILE 210–211
cardioverter-defibrillator, implantable, clinical guidelines, 14 cimetidine, 64
147 education programmes, 9 circuit training
care (health) medical insurance and sports for exercise-based cardiac
collaborative social care and, 23–39 physiotherapy, 372 rehabilitation, 160b
duty of, 5–6 membership, 8 control, 161
inverse, law of, 190b outcome measures, 15 design, 161t
outcome evaluation see outcome Physiotherapy Framework, 9 for functional testing, 296
measures Rules of Professional Conduct, 9 in group work, 276
Care Quality Commission, 14 chemical noxious stimuli and circulation (blood supply/flow)
carpal tunnel syndrome, 562–563 nociception, 382 drugs and, 55–56
carpometacarpal joint of thumb, chemotherapy interferential therapy local effects,
fracture, 513 breast cancer, 624 428
cartilage (articular), fractures involving, bronchial/lung cancer, 120 leg, assessment, 211
500 chest see thorax and entries under thorac- lung surgery, complications, 173t
cast bracing see functional bracing Chester step test, 158 massage contraindicated with
causalgia see complex regional pain childbirth, 609–612 problems in, 479–480
syndrome pelvic floor muscle dysfunction, 607 see also cardiovascular system
cavitation, ultrasound, 437 psychosexual issues, 626 clapping, 485
cell(s) urogenital dysfunction following, Clarke’s test, 243
in inflammatory response, 256 619 clavicular fracture, 510
laser therapy effects, 447 see also delivery; labour clawback, 348
pulsed shortwave therapy effects on children client
membrane, 442–443 asthma aetiology and prevalence, communication barriers from
cellulitis in lymphoedema, 626 95–96 viewpoint of, 184b
central nervous system (CNS), pain/ concussion, 372–373 in health promotion, 200
nociceptive mechanisms, cystic fibrosis use of term, 183
382, 385–386 clinical features, 107 see also patient; service user
see also brain; neurological treatment, 107–109 clinical audit, 15
disorders; spinal cord fractures clinical effectiveness, 12–13
Centre for the Advancement of greenstick, 495 delivery of clinically-effective
Interprofessional growth disturbances with, services, 18
Education (CAIPE), 24 500–501 clinical governance, 9–14
centre of mass, 333, 347–348, 356, proximal radius, 511 continuing professional
358 limb amputation or absence in, 470 development/life-long
centre of pressure, 346, 349–350 resistance training, 280 learning and, 16
Centres for Independent (or see also adolescents; infants and definition, 10b
Integrated) Living, 198 babies clinical guidelines, 13–14
centrilobular/centriacinar emphysema, China, acupuncture national, applied locally, 13
86–87, 86b 20th C., 404 clinical interview see history-taking
cerebellar ataxia, 594 historical use, 403 clinical leadership see leadership
cerebellum and proprioception, 288 Chinese medicine, traditional clinical reasoning, 5, 69–71
cerebral artery occlusion, clinical (acupuncture and), fracture management, 507
features, 591–592 404–405 closed fractures, 495
cerebrovascular accident see stroke Western medicine and, 405, closed kinetic chain exercises, 273,
cerebrum see brain 409–410 278, 290
cervical spine, 225–229, 317–320 chlorpromazine, 64 closed reduction, 501
assessment, 225–229 chorea, 580 closing the loop in reflective practice, 75
case study, 223b chronic obstructive pulmonary disease clothing in massage
lordosis, 288 (COPD), 84–85 patient’s, 478
flexion see flexion basic issues, 84–85 practitioner’s, 475
muscle imbalance and the, 317–320 clinical features/presentations, clubbing (of digits)
cervix in pregnancy, 607–608 87–91 bronchiectasis, 104
dilatation in labour, 610 varying, 91 cystic fibrosis, 107
Charter for Health Promotion, 201 medical treatment, 91–93 fibrosing alveolitis, 117

641
 Index
coaching (by leaders), 50
coaching staff (sports), 378
Cochrane Review, cardiac
rehabilitation, 148, 148t
Code of Professional Values and
Behaviour, 8–9
codeine, 60, 64
cognition
clinical reasoning and, 69
disturbances, 581–582
brain injury, 599
multiple sclerosis, 595
pain and modulatory effect of, 386
cognitive-behavioural therapy, pain, 392
collateral ligaments
ankle
assessment, 248–249
lateral see lateral ligaments
knee
assessment, 242–244
tenderness, 242
colleagues, responsibility to your, 7
Colles’ fracture, 497, 511, 512f
colour, knee, assessment, 241–242
combined movements
cervical spine, 227
lumbar spine, 217–218
common learning, 26t
communication, 183–187
accessible, 195–196
barriers to, from client’s viewpoint,
184b
diversity and flexibility, 196
inclusive, 194–195, 194b, 197–198
models, 184b
neurological conditions affecting, 582
thoracic patients, 177b
see also speech problems
community
care in
amputee, 464t
cystic fibrosis, 109
service delivery, 18
influences on health, 189
community-acquired pneumonia, 110
compact bone healing, 497–498
compartment syndrome, fractures,
499–500
compensations (in imbalance), 312
muscle imbalance, 311t
competence/competency, 6–7
in leadership, developing, 48–50
complaints (patient), 15
complex regional pain syndrome
(Sudeck’s atrophy; reflex
sympathetic dystrophy;
algodystrophy; causalgia),
394
fractures, 500
642
compliance (lungs), 132
compliance with exercise prescription,
300–301
compression (nerve), and associated
syndromes, 561, 563
in pregnancy, 615–616
compression fractures, 495
compression garments (pressure
garments) and bandages
lymphoedema, 626
soft tissue injury, 259
sports injuries, 377
compression tests
acromioclavicular joint, 234
knee, 245
lumbar spine, 219
computed tomography
chest
bronchial/lung cancer, 120
preoperative, 171
previous, records of, 211
concentric contraction and movement,
276t, 277–278, 362
arm elevation, 324t
concussion, 372–373
conduct (professional), rules, 9
congenital bronchiectasis, 103
congenital emphysema, 86
congenital heart disease, cardiac
rehabilitation, 150
congenital limb absence, 470
connective tissue
acupuncture and, 409–410
pregnancy-related changes, 608–609
consciousness
pain and, 381
sports player and loss of (LOC),
372–373
consent (informed)
assessment of older people and
Parkinson’s patients, 544
to exercise, 300
to massage, 478
consolidation, fracture, 498
constipation, 621
multiple sclerosis, 594
continence problems see faeces; urinary
incontinence
Continuing Professional Development
(CPD), 16
sports physiotherapy, 371, 378
continuous passive motion, 517b–518b
continuous positive airways pressure,
post-thoracic surgery,
180
continuous training in exercise-based
cardiac rehabilitation,
160
contract/relax techniques, 284
contractions
cardiac muscle/myocardial, drugs
increasing, 57–58
skeletal muscle
concentric see concentric
contraction
eccentric see eccentric contraction
interferential therapy in
generation of, 428
Oxford Scale of muscle strength,
213b, 274–275, 274t
reciprocal inhibition, 264, 284
resisted, symptoms arising from,
210–211
speed of, effect, 366–367
types, 277–278, 366
uterus
antenatal, 607–608
in labour, 610
contractures, 273
amputated lower limb, 464
Dupuytren’s, 257b
prevention, 266–267
contrecoup lesions, 598
cool-down, exercise-based cardiac
rehabilitation, 161
cooling see cryotherapy
COPD see chronic obstructive
pulmonary disease
coping strategies, pain, 388t
cor pulmonale
COPD, 88
cystic fibrosis, 107
cording (after breast surgery), 624
core stability, 294, 306–308, 312
muscle conferring, 317
Core Standard 6 and neurological
patients, 584b
core strength, 294
coronal plane, pelvic motion in, 337
coronary artery disease (ischaemic
heart disease; CHD),
147–150
epidemiology, 147–148
psychosocial benefits of exercise
training in, 153–154
rehabilitation see rehabilitation
revascularisation see revascularisation
risk factors in, 147
cortical representations of body,
targeting in pain
management, 394
corticosteroids see steroids
cost (economic), interprofessional
education, 26t
see also socioeconomic status
cost-effectiveness (UK)
cardiac rehabilitation, 150
delivery of cost-effective services, 18

couch, massage, 475
cough
in asthma, 96
in bronchiectasis, 104
in COPD, 88
in cystic fibrosis, 93, 107
in lung cancer, 119
in pleurisy, 112
in pneumonia, 111
supported (technique), 178–179
see also haemoptysis
coupling media, massage, 478–479
covering the patient for massage, 478
COX see cyclo-oxygenase
cranial neuropathies in brain injury,
598
cranio-cervical flexion test, 320
creases, lumbar spine assessment,
215–216
crepitus, fractures, 497
critical care patient, rehabilitation in/
after, 141
critical friend, 74–75
critical incident reports, 77
crossover (in gait), 348
cruciate ligaments
anterior
assessment, 244–245
rehabilitation, 278
posterior, assessment, 244
crush fractures, 495
cryotherapy (cooling; ice therapy), 258
compression combined with, 259
elevation combined with, 259–260
fractures, 517
in phase 1 and 2 of healing, 258
in phase 3 of healing, 263
sports injuries, 376–377
CSP see Chartered Society of
Physiotherapy
cueing strategies, Parkinson’s disease,
555, 555t
culture, 187
see also ethnic groups/minority
groups
cutaneous flaps/grafts etc. see skin
cyanosis
asthma, 97
fibrosing alveolitis, 117
cyclo-oxygenase (COX), 60, 62
inhibitors see non-steroidal
anti-inflammatory drugs
cystic fibrosis, 105–110
cytochrome P450 enzymes, 57
D
de qi (acupuncture), 404–405,
409–411
Index
dead leg, 264b diet see nutrition
deafness with neurological disorders, differentiation tests, 213
582 hip joint, 218–219, 236–238, 241b
death, coronary heart disease, 147 knee, 214, 245
decision-making, 69–71 lumbar spine, 237–238
service user involvement, 194–195, muscles/tendons, 214–215
197 shoulder joint, 232
disabled people, 198 vestibular versus vertebrobasilar
decortication of pleura, 174 insufficiency symptoms,
deep venous thrombosis with fractures, 227–228
499 see also structural differentiation
defaecation digit(s) see clubbing; fingers; thumb;
education, 621 toes
obstructed, 621 digitalis drugs (incl. digoxin), heart
post-gynaecological surgery, 622 failure, 57–58
deformities/malalignments (postural) dihydrocodeine, 60, 64
foot/ankle, 247 diplopia, 581
fractures causing, 497 direction-setting, 45
leg, 241, 241f, 247 disability, 190–193
degenerative joint disease, signs and awareness of, 195
symptoms, 214–215 communication, and the barrier,
see also osteoarthritis 185–186, 195
delayed-onset muscle soreness, 273, cultural/ethnic dimensions, 187–188
276–277 decision-making involving people
delegation, 16–17 with, 198
delivery definitions, 190b, 192
Caesarean see Caesarean section equality training, 195
vaginal (2nd stage of labour), 610 health professionals and their
assisted, 611 relationship with, 195
deltoid, 322 inclusion and involvement of
deltopectoral approach to shoulder people with, 198
arthroplasty, 525 labelling people with, 183b
dementia, 551 from low back pain
demyelination in multiple sclerosis, predictors, 223–224
593 treatment of biopsychosocial
deoxyribonuclease in cystic fibrosis, aspects, 225
108 measures, in pain, 389–390
depersonalisation, 197 models, 190–193, 195
depolarisation, nerve, 417 see also International Classification
dermatome tests of Functioning, Disability
cervical spine, 228 and Health
lumbar spine, 219 discharge (and return home/return to
detrusor disorders function and active lifestyle)
multiple sclerosis, 594 amputee, planning, 464t
women, 619 breast surgery, 625
diabetes mellitus from cardiac rehabilitation,
in cystic fibrosis, 107 planning, 165–166
exercise-based cardiac rehabilitation cardiac rehabilitation immediately
and, 163 after (=phase II), 150
massage contraindicated, 479 exercise prescription, 164
diamorphine, 60 femoral shaft fracture, 522
diary, reflection, 78 gynaecological surgery, 622
diastasis (in pregnancy) hip arthroplasty rehabilitation after,
rectus abdominis, 615 535
symphysis pubis, 613 from intensive care, outpatient
diathermy, shortwave and microwave, physiotherapy-led exercise
433–434 programme after intensive
diazepam, 64 care, 143
diclofenac, 64 thoracic surgery, 180
643
 Index
discoloration, knee, 241–242
discrimination
cultural, 187–188
institutionalised, 186, 187b
Disk/Accuhaler, 99
dislocation
hip replacement, 508t
shoulder, 268b
displacement
angular see angular displacement
of fracture, 495
distraction tests
acromioclavicular joint, 234
menisci versus ligaments, 245
distribution of drug, volume of, 63
diuretics, 58
diversity in communication, 196
DNase in cystic fibrosis, 108
doctor in sports, 377–378
dopamine, Parkinson’s disease and, 59,
541–542, 548
dopamine agonists, 59
doping in sport, 372
dorsal horn and pain, 382, 385
dorsiflexion, 220–222, 221f, 248,
335–336, 362
exercises increasing, 285
in slump test, 567
dosing (drug), 57
double crush syndrome, 563
drainage
chest (with intercostal drains),
174–175
manual lymphatic (by massage),
lymphoedema, 491, 616
postural see postural drainage
draping the patient for massage, 478
draw tests
ankle, 249
knee, 242–244
shoulder, 234
DRIFT (duration, repetition, intensity,
frequency, technique),
transversus abdominis
rehabilitation, 317, 317t
drug(s) (medication), 53–65
commonly encountered, 57–61
delivery systems
asthma, 99
COPD, 92–93
fracture union affected by, 499
glossary, 63–65
history-taking, 211
amputee, 461t
soft tissue healing affected by, 262
sports and doping and, 372
see also pharmacology
drug therapy
arrhythmias, 57
644
asthma, 98–99
guidelines, 100–101
COPD, 92
cystic fibrosis, 108
inflammation see anti-inflammatory
drugs
motor neurone disease, 597b
multiple sclerosis, 595
see also medical management and
specific (types of) drugs
dry power inhalers, 99
dual channel output in TENS, 421
Dupuytren’s contracture, 257b
duty of care, 5–6
dynamic exercise, lymphoedema, 626
dynamic splints, metacarpophalangeal
joint replacement, 529
dynamic stretching, 282
dynamometer
handheld, 367
isokinetic (isokinetic machine), 213,
275, 289–290, 367–368
dysarthria, 582
dyskinesia, Parkinson’s, 541
dysphagia see swallowing difficulty
dysphasia, 582
dyspnoea (shortness of breath)
asthma, 96
bronchial/lung cancer, 120
bronchiectasis, 104
COPD, 88
cystic fibrosis, 107
fibrosing alveolitis, 117
MRC scale, 85t
pneumonia, 111
dysrhythmias see arrhythmias
dystonia, 580
E
eccentric contraction/movement/
exercise, 276–278,
276t–277t, 300, 362
arm elevation, 324t
hip extension, 292f
treatment with, 277–278
ECG (electrocardiogram), asthma, 97
economic factors see cost;
socioeconomic status
education (patient information and
advice; teaching)
antenatal, exercise, 614, 616–617
asthma, 102
cardiac rehabilitation, evidence for,
148–149
case studies, 543b
gynaecological surgery,
postoperative pelvic floor
muscle exercises, 622
in health promotion, 189
interprofessional see
interprofessional
education
mental capacity, 544b
muscle imbalance, 312t
pain
biology, 392
lumbopelvic, in pregnancy, 614
Parkinson’s disease, 544b
prosthetic wearing, 465–467
stretching exercises, 277–278
education and learning (profession of
physiotherapy), 9
educator role in interprofessional
education, 30
effectiveness see clinical effectiveness;
cost-effectiveness
effleurage, 481
effusions
knee, 209, 242
pleural, 113
eformeterol, 92
elastic components in series,
plyometrics and, 295
elastic opposition to lung expansion,
131–132
elbow (and elbow joint)
arthroplasty, 528
fractures, 510–511
moments, 366
calculation, 354, 356
elderly see older people
electric field in pulsed shortwave
therapy, 442
electrical stimulation, 419–432, 420f
functional (FES), 431, 589–590
general principles, 420
nerve, transcutaneous see
transcutaneous electrical
nerve stimulation
neuromuscular see neuromuscular
electrical stimulation
in urogenital dysfunction, 620
electrocardiogram (ECG), asthma, 97
electrodes
in functional electrical stimulation,
438
in interferential therapy, 429
in shortwave diathermy, 434
in TENS, 421, 422f
placement, 424
electrophysical agents see electrotherapy
electrotherapy (electrophysical agents),
417–455
grouping of modalities, 419–420
mechanisms (in general), 417
model of, 418
therapeutic windows, 223, 418–419

in tissue healing and repair see
healing and repair
see also electrical stimulation
elevation of limb
arm
concentric movement, 324t
scapulothoracic joint muscles in,
321t
in injury
to soft tissues, 259–260
sports injuries, 377
residual limb (after amputation),
459, 459f
elimination constant, 62
embolism
fat, with fractures, 499
pulmonary, with fractures, 499
emphysema, 86–87
subcutaneous, 115
employment (occupation; work)
asking questions relating to, 208
blue and black flags and, 389
functional tests in rehabilitation for,
296
health affected by conditions of,
189
empowerment, service user, 192–194,
194b, 200–201
empty can test, 235
empyema, 113–114, 171
end-feel with passive movements, 213
end-range squats, 327
endosteal proliferation, fracture,
497–498
energy, 360
conservation, 361
costs, leisure activities, 156t
kinetic, 361
linear, 360
potential, 360–361
‘energy-based’ window for
electrotherapy, 419
Entonox in labour, 611
environment
amputee difficulties relating to, 460
asthma management, 101
as disability barrier, 192
working, affecting health, 189–190
enzymes
as drug targets, 55f
in soft tissue injury, 255
epicondylitis, lateral (tennis elbow),
491, 577
epidural analgesia/anaesthesia
childbirth, 611
thoracic surgery, 176
epilepsy
drug management, 61
post-traumatic, 598
epinephrine (adrenaline), 63
epiphysis, fractures affecting, 500
episiotomy, 611
equality training, disability, 195
equilibrium, static, 345
equipment for sport events, 375, 378
Equity and Excellence: Liberating the
NHS, 27
ethical issues, 5–6
older people and Parkinson’s
patients, 544
ethnic groups/minority groups
cardiac rehabilitation, 149
culture and, 187–188
eversion, foot, 248, 248b
evidence-based practice (incl. evidence
from research), 10–12
neurological patients, rehabilitation,
587
rehabilitation in critical care setting,
142–143
see also research
examination see assessment; physical
examination
EXCITE trial, 588
exclusion, 197
excretion, drug, 57
exercise (and physical activity),
273–303
abdominal, post-gynaecological
surgery, 622
acute respiratory distress syndrome,
116
ankle arthroplasty, 537
breast cancer surgery, postoperative,
624
in cardiac rehabilitation see exercise
training
compliance see compliance
coronary heart disease and levels of,
148
femoral shaft fractures, 520–521
group, 298–299
hand, massage practitioner, 476
hip arthroplasty, 534–535
knee arthroplasty, 532
lymphoedema, 626
mobilising see mobilisation
movement dysfunction and value
of, 286–287
neurological patients, 587–588
older people, 552–554
in falls prevention, 554
outpatient physiotherapy-led
programmes of, after
intensive care, 143
in pain management
graded, 393–394
pacing, 393
Index
Parkinson’s disease, 552–554
case study of prescription, 556t
in falls prevention, 554
pelvic floor see pelvic floor muscles
in pregnancy, 614–618
advice, 614, 616–617
benefits, 616
contraindications, 616
types, 617
prescription, 300–301
in cardiac rehabilitation, 154–157
soft tissue injuries, 263
progression see progression
shoulder see shoulder
soft tissue injuries, 267
grading level of activity,
263–265
prescription, 263
strengthening see strength
thoracic surgery, postoperative,
178–179
see also breathing control; fitness;
retraining/re-education;
sports; thorax, expansion
exercises
exercise tolerance
in bronchiectasis, increasing/
maintaining, 105
in COPD
increasing/maintaining, 93
reduced, 90
in cystic fibrosis, increasing, 109
in pneumonia, increasing, 112
test (in cardiac rehabilitation), 154,
156, 158
exercise training in cardiac
rehabilitation, 152
contraindications, 154, 159, 162
definition (of exercise training), 152b
prescription, 154–157
assessment for, 154
and delivery across four phases
of cardiac rehabilitation,
164–166
programming, 158–162
risk stratification, 157–158
special populations, 162–164
exertion, rating of perceived, 155–156
expectation of pain, 386
expert opinion, 11
expiration, 130, 132
COPD, 88
emphysema, 87
with inhalers, 102
see also forced expiration technique;
forced expiratory volume
in one second; peak
(expiratory) flow; positive
end-expiratory pressure
645
 Index

extension feedback obesity, 164

cervical, 226–227, 318t 360°, 50 older adults, 163
hip, 239 patient, 15 peripheral vascular disease, 163
eccentric control, 292f feel see palpation respiratory conditions, 164
knee, 219, 336, 362 feet see foot transversus abdominis
osteoarthritic versus normal females see women rehabilitation, 317
knee, 341 femoral nerve stretch (prone knee fixation (fracture), 499–500, 503
resisted, 220f bend), 221, 570 femoral shaft fracture, 515
in slump test, 567 femur tibial/fibular fracture, 515–516
lumbar, 216–217 amputation through, 469f time to union with, 499
repeated, 218 gait deviations, 469 flags, 389
shoulder, 233 hip contractures, 464 low back pain, 224b
horizontal, 232 prostheses see prostheses flat back, 216
extensor strengthening exercises, fracture, 513–515 flexibility
shoulder, 286f case study, 519b–522b in communication, 196
external fixation, 504 condylar, 515 in movements, relative, 310–311
tibial fracture, 516 neck, 513–514 flexion
extracorporeal shockwave therapy, shaft, 515, 519b–522b cervical/neck, 226, 318t
448–450 in knee arthroplasty, prosthesis passive, assessment, 220, 566
extraneural dysfunction, 562 component, 536 in slump test, 567
exudates Femurett, 465 cranio-cervical flexion test, 320
inflammatory, 262 fentanyl, 60, 64 hip joint, 219, 239
pleural, 113 ferrous sulphate, 64 contractures, amputees, 464
fertility problems (male) in cystic and knee, 240f
fibrosis, 107 knee, exercises increasing, 285
F
fetus, 608 knee, passive, 243
FABER (flexion plus abduction plus see also childbirth and hip, 240f
external rotation) test, 219 FEV1 see forced expiratory volume in knee, in walking/gait, 241b, 243,
faeces (stools) one second 335–336, 362
in cystic fibrosis, 107 fibrosing alveolitis, 117 amputee, abnormalities, 468
incontinence (anal/stool fibrous repair phase of healing see osteoarthritic versus normal
incontinence), 582, healing and repair knee, 341
620–621 fibular fracture, 504f, 515–516 lumbar, 216
obstetrically-related, 618 fight or flight response, 56 repeated, 218
see also constipation; defaecation fingers plantar, 219–220, 220f, 248,
fall(s) arthroplasty, 528–529, 531f 248f–249f, 335
amputee, 468 clubbing see clubbing shoulder joint, 231–232
older people, 550–551 fractures, buddy strapping, 502 exercises with, 285
femoral neck fracture, 513–514 see also thumb horizontal, 232
physical activity and exercise in first aid, sports, 369–371, 374–377 thoracic, in slump test, 567
prevention of, 554 first pass metabolism, 62 see also dorsiflexion; FABER test;
Parkinson’s patients, 550–551 fitness, physical/cardiopulmonary/ lateral flexion; side-
prevention, 554, 556t cardiovascular flexion; sitting flexion;
fallopian tubes, 607 athletes, 258b standing flexion
Faradism, 429 in exercise training for cardiac flexors, cervical/neck, deep, 318
fascia rehabilitation, 158 assessment of impairment, 320
lift and roll, 487 maintenance and improvement fluid displacement test, knee, 242
muscle see myofascia cystic fibrosis, 109 see also effusion; exudate; oedema;
fasciectomy, Dupuytren’s contracture, pneumonia, 112 swelling
257b in risk stratification for exercise- fluoxetine, 64
fast-twitch (type IIa/IIb) muscle fibres, based cardiac foot, 246–250
130, 278, 279t, 317 rehabilitation, 158 assessment, 246–250
fat embolism with fractures, 499 FITT principle (frequency/intensity/ fractures, 517
fatigue, 582 time/type) in exercise Football Association (FA), 369–370
multiple sclerosis, 594–595, 594b training, 154–157 force(s), 344–350
respiratory muscle, 132–133, 135 in special patient groups on body, 346–349, 354–359
fatigue fracture see stress fracture arthritis, 164 ground reaction see ground reaction
fear–avoidance beliefs (with pain), diabetes, 163 forces
reducing impact, 394, 397 hypertension, 163 horizontal see horizontal force

646

joint see joint
methods of analysis, 350
moment of see moment
muscle see muscle
resolving (in calculation of
moments about joints),
354–355, 358–359
understanding, 344–345,
350–351
in ventilation, opposing, 131–132
vertical see vertical force
force platforms, 350
forced expiration technique (FET)
bronchiectasis, 105
COPD, 94
thoracic surgery patient, 178
forced expiratory volume in one
second (FEV1)
asthma, 97
COPD, 85
cystic fibrosis, 107
forced vital capacity (FVC)
asthma, 97
positioning improving, 179b
forceps delivery, 611
forefoot examination, 247–248
forward head (poking chin) posture,
225, 226f, 319–320
four-pole interferential therapy,
426–427
‘four’ test (Faber test), 219
fractures, 495–523
causes, 496
classifications, 495–496
and time to union, 499
clinical features, 496–497
commonly encountered sites of,
510–517
complications, 499–501
see also specific fractures
definition, 495b
healing, 497–499
low-intensity ultrasound therapy
and, 440
time for full healing, 498–499
humeral see humeral fracture
management, 501–506
case study, 519b–522b
physiotherapy, 506–510
principles, 501–506, 510–517
pathological, 496
traumatic brain injury combined
with, 599
France, acupuncture, historical use,
403
free active exercises see active exercises
free-body analysis, 345
freezing of gait in Parkinson’s disease,
549–550, 554
frequency (stimulation/pulse) in
electrotherapy
frequency windows, 419
interferential therapy, 424–426
sweep patterns, 427
TENS, 421, 423
selection, 424
friction massage technique, 488
Achilles tendonitis, 491
tennis elbow, 491
frictional forces opposing airflow,
132–133
function, body (and functional capacity)
amputees, assessment, 461t, 470
in exercise-based cardiac rehabilitation,
in risk stratification, 158
fractures and loss of, 497
in neurological patients, 583
measures of, 584–586
older people, in outcome measures,
553t
pain impact on, measurement,
389–390
Parkinson’s disease, in outcome
measures, 553t
return to see discharge
in WHO ICF, 387
promoting optimal function (in
pain patient) with
reference to, 390
functional bracing (cast brace), 503
femoral shaft fracture, 519–521
functional disability see disability
functional electrical stimulation (FES),
431, 589–590
functional instability, 288–289
potential causes, 273
structural instability and, 289b
Functional Measure of the Amputee, 470
functional MRI, acupuncture research,
404
functional tests (incl. movements), 286
ankle/foot, 248
fractures, 509
hip, 240
and rehabilitation, 286
shoulder, 233
functional tools in strength assessment,
275
furosemide, 64
G
G-coupled protein receptor, 62
gabapentin, 64
gait (walking manner), 331–368
amputee
assessment with prosthesis, 461t
deviations, 468–469
Index
analysis, 331–368
development of equipment,
343–344
ankle/foot and, 246, 359
cycle, 332
ground reaction forces during,
346–349
joint moments during, 359–360
joint movements during,
333–338
joint power during, 362
hip joint and, 235–236, 359–360
knee joint and, 241, 359
neurological patient, examination,
583
older people, 549–550
Parkinson’s disease, 549–550
freezing of, 549–550, 554
spatial and temporal parameters,
332–333
GAITRite™ system, 343
Galeazzi fracture, 511
older people, 549–550
Parkinson’s disease, 549–550
gallow’s traction, femoral shaft fracture,
515
Garden classification of femoral neck
fracture, 513
gastrointestinal tract
brain injury and, 598–599
in multiple sclerosis, 594
NSAID adverse effects, 60
gate control theory of pain, 391, 407
genitourinary dysfunction, 618–620
see also reproductive tract
GENTLE, 589
genu recurvatum, 241
genu valgum, 241, 515
genu varum, 241
German Acupuncture Trials (GERAC),
408
Gibbs’ model of reflection, 80
Glasgow Coma Scale, 598, 598t
glenohumeral joint
assessment, 232–234
muscle acting on (and muscle
imbalance and movement
faults), 306–308, 321–323
gliclazide, 64
glucocorticoids see steroids
glyceryl trinitrate, 58, 64
glycosides, cardiac, 57–58
goals (agreeing and setting)
fractures, 509–510
neurological patient, 586
Parkinson’s disease, 546,
551–552, 555, 556t
older people, 546
falls, 551
647
 Index
Golgi tendon organ, 288t, 289f
goniometer, 355–356
knee, 243
governance see clinical governance
graded activity versus graded exposure
in pain management,
393–394
gravity
acceleration and, 345
active-assisted exercises and, 274
greenstick fractures, 495
grief process, amputation, 459b
ground reaction forces (GFRs), 345–346
in gait cycle, 359–360, 362
lower limb moment calculation
and, 354–355, 357–358
methods of showing, 350
groups
exercise in, 298–299
in pregnancy
antenatal, 617–618
postnatal, 618
growth, fractures affecting, 500–501
guidelines see clinical guidelines
gym ball, amputee, 464
gym work in pregnancy, 617
gynaecological disorders, 618–620
surgery see surgery
H
hacking, 485
haematological complications of
fractures, 499
haematology (tests)
pneumonia, 111
tuberculosis, 119
haematoma, fracture, 497
Haemophilus influenzae pneumonia, 110
haemoptysis
bronchial/lung cancer, 120
bronchiectasis, 104
cystic fibrosis, 93–94
haemorrhage, brain/intracranial
stroke due to, 591
subarachnoid, 591–592
half-life, 62
hallux valgus and rigidus, 248
hamstrings
eccentric training, 277–278
injury, 264b, 267b, 269b
neurodynamic assessment and
treatment, 577
length assessment, 236–237
hands
arthroplasty, 528–529
fractures, 512–513
massage practitioner’s, 476–478
reaching task, kinematics, 339–340
648
head
forward head (poking chin)
posture, 225, 226f,
319–320
injury, 310–311
management, 599
sports, 372–373
see also brain
headache, acupuncture, 408
healing and repair (tissue - primarily
soft tissue), 253–271
case studies, 253, 269b–270b
continuum of, 254–255
injury severity and progression
through, 260
electrotherapy in, 265
pulsed shortwave therapy, 443
ultrasound, 437
fracture see fractures
massage too early in process of, 480
phase 1 (bleeding - 0-10 hours),
254–255
physiotherapy interventions,
256–260
phase 2 see inflammation
phase 3 see proliferation stage
phase 4 see remodelling stage
health
behaviour and see behaviour
definitions, 188, 188b
inequalities, 188–190, 199
promotion, 198–202
women’s see women
see also International Classification
of Functioning, Disability
and Health
Health and Care Professions Council
(HCPC - formerly the
HPC), 3, 7–8
interprofessional education and, 27
reflective practice and, 71
Health and Safety (First-Aid)
Regulations (1981), 369
health outcomes of care, evaluation see
outcome measures
Health Professions Council see Health
and Care Professions
Council
Health Professions Order, 3
health services see services
healthcare see care
hearing (auditory) disturbances,
neurological conditions
with, 582
heart
adverse events during exercise-based
cardiac rehabilitation, 157
drugs acting on, 57–58
rate, in exercise training, 154–155
tamponade, acupuncture needling
and risk of, 406
transplantation, 149
valve surgery, 150
heart disease
congenital, 150
coronary see coronary artery disease
older people, 546t
rehabilitation see rehabilitation
heart failure (chronic), 162
cardiac rehabilitation, 148–149
exercise-based, 162
in cor pulmonale, 88, 90f
heat/heating see humidification and
entries under thermal
heel
lift, 335–336, 347–348
strike, 334–336, 346–349,
357–360, 362
hemianopia, 581
hemiarthroplasty
hip, 514
humeral (proximal) fracture, 526
heparin, 64
hepatic… see liver
heroin (diamorphine), 60
hierarchy of evidence, 11
High Quality Care for All: Next Stage
Review Final Report,
42–43
High Quality Workforce: Next Stage
Review Report, 42–43
hindfoot examination, 247–248
hip (hip joint), 235–240
angle, 333
assessment, 218–219, 235–240
contractures in amputees, 464
extension see extension
flexion see flexion
fracture, 513–514
hemiarthroplasty, 514
knee versus, as source of symptoms,
differentiation, 241b
lumbar spine versus, as source of
symptoms, differentiation,
218–219, 237–238
moments, 358
in gait, 359–360
motion in sagittal plane, 336–337
pain referred to knee, 208
power during walking, 362
total replacement (arthroplasty),
531–535
complications, 533
revision surgery, 535
histo(patho)logy, lung cancer, 120,
120t, 169–171
history
acupuncture, 403–404

health promotion, 199
interprofessional education, 24
mechanical ventilation, 135
movement analysis systems, 343–344
profession of physiotherapy, 2–3
history-taking (clinical interview),
210–211
amputee, 461t
fractures, 508
neurological patients, 583
Parkinson’s disease, 546–547
older people, 546–547
pain patient, 388t
hi-TENS, 423
hold/relax techniques, 284
home, return to see discharge
horizontal flexion and extension of
shoulder joint, 232
horizontal forces, 345
knee, 355
upper limb, 357
hormones in pregnancy, 608
hospital
cardiac rehabilitation as in-patient
(=phase I), 150, 164
discharge see discharge
outpatient see outpatient
postnatal physiotherapy as
in-patient, 618
hospital-acquired (nosocomial)
pneumonia complicating
acute respiratory distress
syndrome, 116
hot packs, 433
human relations, 196
humeral fracture, 510–511
complex, hemiarthroplasty, 526
condyle, 510–511
neck, 510
proximal, 510
shaft, 510
humidification (incl. heated
humidification)
COPD, 94
cystic fibrosis, 109
thoracic surgery patient, 180
hydrocephalus, post-traumatic, 598
hydrocollator packs, 433
hydrocortisone, 64
hydrotherapy see water-based exercises
5-hydroxytryptamine, 61
hyperalgesia, 385, 385b
hypercapnia, chronic, 122
hypercapnic (type II) respiratory
failure, 121–122, 133–134
hyperinflation
manual, 140–141
pathological, adverse effects,
106–107, 134–135
hypertension, exercise-based cardiac
rehabilitation and, 163
hypnotics, 59
hypokinesia, Parkinson’s, 541
hypotonia, 581
hypoventilation, alveolar, 133–134,
134t
hypovolaemic shock, fractures, 497
hypoxaemic (type I) respiratory failure,
121–122, 133
hypoxic drive, 135
I
ibuprofen, 53b, 60, 64
ice burns, 258
ice massage, 479
ice therapy see cryotherapy
identity, professional, 33–34
iliac spine
anterior superior, 315–316
posterior superior, 315
iliopsoas, 314t
problems, 314t
restriction (versus rectus femoris
restriction), 236
iliotibial band, 236
Ilizarov method, 505b
imaging
brain, acupuncture research,
407–408
thoracic surgery, preoperative,
171
see also specific modalities
immobilisation
fracture, 502–506
proprioceptive deficits with, 287t
immotile cilia syndrome, 103
immunisation, tuberculosis, 119
immunology, tuberculosis, 119
impact of pain, measures, 388
impairments, 581, 583–584
definition, 192
as outcome measures, 585t
impingement, shoulder, 232, 232b,
322–323
test, 235
implantable cardioverter-defibrillator,
147
incentive spirometry, 179
inclusion, 194–195, 194b, 197–198
income, low see socioeconomic status
incontinence see faeces; urinary
incontinence
incremental walking programme, 164,
165t
independence
amputees, 464, 464t
definition, 191, 191b
Index
individual see entries under person;
personal
inertia, 344
infants and babies, cystic fibrosis,
106–107
treatment, 107, 109
infections
fractures and risk of, 499
tibial/fibular, 516
respiratory see respiratory infections
skin see skin
see also antibiotics
inferior draw (sulcus) test, shoulder, 234
infertility (male) in cystic fibrosis, 107
inflammation, 253–271, 391
acute
massage contraindicated, 480
pulsed shortwave therapy, 443
in soft tissue injury see
subheading below
ultrasound therapy, 437–439
management, 391
peripheral mediators, 384f, 385
pharmacological management see
anti-inflammatory drugs
in soft tissue injury (phase 2 of
healing and repair),
255–256
case study of ankle sprain,
395–396
physiotherapy interventions,
256–260
see also anti-inflammatory effects
inflammatory arthropathies see arthritis
influence, spheres of, 47–48
influenza, 110
information see education
informed consent see consent
infrared radiation, 433
inhaled analgesia in labour, 611
inhalers
asthma, 99
technique, 101–102
COPD, 92–93
injury, traumatic see trauma
In-Motion, 589
inpatient see hospital
in-shoe pressure analysis, 350
insidious onset of condition, 210
inspiration, 130–131, 131f
with inhalers, 102
muscles involved, 132
training, 93–94
instability, 288–289
assessment see stability
postural, in Parkinson’s disease,
541–542, 548
institutionalised discrimination, 186,
187b
649
 Index
instrumental (assisted) vaginal delivery,
611
insulin, 64
insurance (medical) and sports
physiotherapy, 372
intensity of stimulation in TENS, 424,
431
intensive care, rehabilitation in/after,
141
intercostal drains, 174–175
interface treatment (neurodynamic),
575
interferential therapy, 424–429
interferon-β, multiple sclerosis, 595
intermittent positive pressure
breathing/ventilation
COPD, 94–95
thoracic surgery patient, 180
internal fixation, 503
tibial/fibular fracture, 516
International Classification of
Functioning, Disability
and Health, 387,
543–544, 583–584
promoting optimal function with
reference to, 390
International Classification of
Impairment, Disability
and Handicap (1980), 192
international dimensions of
interprofessional
education, 25–26
International Organization of Physical
Therapists in Women’s
Health, 1–2
interphalangeal joint, foot, assessment,
250
interpreters (language), 195–196
interprofessional education, 23–39
collaborative working and, 28–29
definitions, 24, 24b
history, 24
international dimensions, 25–26
key points for success, 29b
in practice, 29–33
technology and, 31
UK context, 26–29
interprofessional networks, 50
interprofessionalism, 33–34
interval training in exercise-based
cardiac rehabilitation, 160
intervertebral movements, passive
physiological
cervical spine, 227
lumbar spine, 218–219
interview
clinical see history-taking
pain patient, 387
case studies, 395–397
650
intestine see bowel; faeces;
gastrointestinal tract
intra-articular adhesions with fractures,
500–501, 522
intra-articular fractures, 500
intracranial haemorrhage see
haemorrhage
intramedullary nailing, 504
intraneural dysfunction, 562
invasive ventilation, 135–136
inverse agonist, 62
inverse care law, 190b
inversion, foot, 248, 248b
investigations (previous), recording
results, 211
involuntary movements, Parkinson’s,
541
ion channels as drug targets, 55f
ionization of drugs, 55, 62
iPAM, 589
irritability of condition, determination,
210
ischaemia
cerebral see ischaemic stroke;
transient ischaemic attack
in soft tissue injury, 255
ischaemic attack, transient, 593
ischaemic stroke, 591
isokinetic assessment (machines/
dynamometer), 213, 275,
289–290, 367–368
isometric contraction and forces, 276t,
277–278, 362
isotonic shortening and lengthening,
276b
J
jargon, 197–198
Johns’ model of reflection, 80
joints (articulations)
adhesions in/around, with fractures,
500–501, 522
angle, definition/calculation,
333–334
assessment (peripheral/non-spinal),
230–250
degenerative disease see
degenerative joint disease;
osteoarthritis
forces (and their calculation),
355–356
spine (base), 358–359
upper limb, 356–357
fractures involving, 500
inflammatory disease see arthritis
moments, 354–360
body segment inclination and,
364
elbow, 354, 356, 366
lower limb, 354–355, 357–360
movements see mobilisation;
movements; range of
movements
pelvic, female
anatomy, 605–606
in pregnancy, dysfunction, 614
in pregnancy, normal changes,
605–606, 608–609
power during walking, 362
receptors in proprioception, 288
replacement see arthroplasty
sensing of position and movement
see proprioception
stability see instability; stability
K
Kartagener’s syndrome, 103
Karvonen formula, 155
kinematics, 332–333
hand in reaching, 338–340
knee in walking, 340–342
shoulder complex, 325
kinetic chain exercises, 273, 290
kinetic energy, 361
kinetics, definition, 346
Klebsiella pneumoniae, 110
kneading, 481–483
knee (joint), 325–327
angle, 333
assessment, 241–243
with femoral shaft fractures, 519
bend, prone, 221, 570
contractures in transtibial
amputation, 464
extension see extension
flexion see flexion
fractures around, 515
moments, 355, 358–359
in gait, 359
motions and their analysis (in
walking), 335–336, 341
muscle imbalance and, 325–327
osteoarthritis
acupuncture, 408
kinematics, 341–342
power during walking, 362
replacement, 535–537
knock-knees (genu valgum), 241, 515
knowledge
clinical reasoning and, 69
of self reflective practice, 77
specific to profession, possessing,
4–5
sports physiotherapy, 370–374
Kolb model of reflection, 79
kypholordosis, 216
 Index

length contractures, 464

L
leg, discrepancy, 236 oedema, 464
labelling people, 183b of lever (in exercise), changing, pain, 459
labour, 609–612 285–286 poor condition, 460
1st stage, 610 muscles shape, 464b
2nd stage see delivery adaptations, 309 teaching how to care for,
3rd stage, 611 increasing (=lengthening) in 466–467
definition, 609b management of children with absence of, 470
induction, 611 imbalance, 312t elevation see elevation
onset, 609–610 muscles, tests, 214 proprioceptive exercises, 291–293
see also childbirth hamstrings, 237f see also compartment syndrome;
Lachmann’s test hip, 237 lower limb; upper limb
knee joint, 211, 245 muscle imbalance and, 311t limbic system
shoulder, 234 shoulder, 231, 233 acupuncture and, 409
lactation, 612 step, 332 damage, 582
language stride see stride linear acceleration, 338
as communication barrier, 187 leukotriene antagonists, asthma, 98 reaching task, 339–340
inclusive, 197–198 levator scapulae, 321–322 linear displacement, 338
interpreters, 195–196 length test, 231 reaching task, 339
lansoprazole, 64 lever (in exercise), changing length, linear energy, 360
large cell lung cancer, 120t 285–286 linear models of communication, 184
Lasègue’s see straight leg raising test levodopa, 59 linear power, 360
laser phototherapy, bronchial/lung life-long care, amputee, 463t, 467–468 linear velocity, 338
cancer, 120 life-long learning (LLL), 16 reaching task, 339
laser therapy, 444–448 definition, 16 linear work, 360
lateral epicondylitis (tennis elbow), emphasis on, 16 LIPUS (low-intensity pulsed
491, 577 lifestyle ultrasound) and fracture
lateral flexion in cervical spine, active, return to see discharge healing, 439–440
318t coronary disease risk factor, 147 liver
lateral ligaments (lateral collateral older people and Parkinson’s cystic fibrosis-related disorders, 107
ligaments) disease and impact on, drug handling, 57
ankle 544b metastases from lung cancer, 120
assessment, 248 lift and roll, fascial, 487 living conditions see socioeconomic
injury, 261b, 268b ligaments status
knee, assessment, 244 ankle load
lateral meniscus tests, 245 assessment, 246, 248–249 excess (overload) in muscle
lateral sclerosis injury, 246, 257b, 264b, 268b strengthening, 274, 279
amyotrophic, 596 differentiation tests, 214 muscle strength evaluation and, 364
primary, 596 knee lobes of lung, 169
lateral shift (lumbar spine), 216 assessment, 243–245 excision (lobectomy), 173
law see legal issues differentiation tests of menisci lobular pneumonia, 111
LDL cholesterol, drugs lowering levels and, 214, 245 local anaesthetics, 61
of, 58 lumbar spine, anterior and Locomotor Capabilities Index, 469
leadership (clinical), 41–52 posterior, assessment, 212, look see observation
case for, 47 219 loop diuretics, 58
competency development, 48–50 pelvic, in pregnancy, 608 lordosis, 216f
context, 42–43 see also specific named ligaments cervical, assessment, 288
role and service improvement, light absorption by tissues in laser lumbar, transfemoral amputee, 469
45–47 therapy, 446 see also kypholordosis
learning cycle, Gibbs’, 79f limb(s) lo-TENS, 423
see also education and learning amputation see amputation low back pain (LBP), 223–225
leg see lower limb amputees’ remaining acupuncture, 408
legal issues (law/legislation/ (non-amputated) assessment, 223–225
regulations), 7–8 assessment, 461t case study, 396–398
ethical older people and Parkinson’s teaching how to care for, management guidelines, 224
patients, 544 466–467 low-density lipoprotein cholesterol,
massage, 479 amputees’ residual (after drugs lowering levels of, 58
sports management, 369–372 amputation) low-intensity laser therapy (LILT),
leisure sports see sports assessment, 461t 444–448

651
 Index
low-intensity pulsed ultrasound and
fracture healing, 439–440
low-level laser therapy (LLLT), 444–448
lower limb (and leg)
alignment, 247
amputation see amputation
arthroplasty, 531–537
circulatory assessment, 246
fractures, 513–517
girth, assessment with femoral shaft
fractures, 521t
length discrepancy, 236
moments about joints in, 354–355,
357–360
neurodynamic tests, 568–570
power in joints of, 362
proprioceptive exercises, 291–292
walking see walking
see also dead leg; straight leg raising
test
lubricant, massage, 478–479
lumbar spine, 215–225
assessment, 215–225, 237–238
case study, 223b
lordosis, transfemoral amputee, 469
in pregnancy, 608
pain, 612–613
lumbopelvic region, 312
pain in pregnancy, 612–615
management, 614–615
stability, 312, 314–315, 606
testing, 222
see also pelvis
lung(s)
abscess, 117–118
acupuncture needle injury to, 406
anatomy, 169, 170f
clearing fields see secretion
compliance, 132
in cystic fibrosis, 106
disease (in general), opposing
forces in, 132
drugs acting on, 58–59
emphysematous changes, 87f
expansion
elastic opposition to, 131–132
re-expansion in pneumonia, 112
interventions by respiratory
physiotherapist, 140–141
obstructive disease see obstructive
pulmonary disease
oedema
acute respiratory distress
syndrome, 116
cor pulmonale, 88
operations, 173
complications, 169
resection (pneumonectomy),
171, 173
652
rehabilitation see rehabilitation
restrictive disease see restrictive
pulmonary disease
tumours, 119–121, 169–171
imaging, 171
ventilator-associated complications,
137–139
see also respiratory disease
lung function tests
asthma, 97
COPD, 83–84
cystic fibrosis, 107
thoracic surgery, preoperative, 171
see also spirometry
lying
shoulder flexion exercise, 285
supine, hip examination, 236
see also prone knee bend
lymph nodes in breast cancer, 624–625
lymphatic massage, lymphoedema,
491, 616
lymphoedema, 625–626
manual lymphatic drainage (by
massage), 491, 616
women, 625–626
cancer patients, 625
M
McConnell critical test, 243
McGill Pain Questionnaire, 388
McMurray’s medial and lateral
meniscus tests, 245
magnetic field in pulsed shortwave
therapy, 442
magnetic resonance imaging (MRI)
functional, acupuncture research, 407
records of previous MRI, 211
malalignments see deformities
males see men
malignant multiple sclerosis, 594
malignant tumour see cancer
malleolar fracture, 516, 516f
manipulation techniques in massage
see massage
manual hyperinflation, 140–141
manual lymphatic drainage (massage),
lymphoedema, 491, 616
manual techniques/therapy
lumbopelvic pain in pregnancy, 614
respiratory (incl. ventilated)
patients, 141
march fracture, 517
mass, 345
centre of, 333, 347–348, 356, 358
distinction from weight, 345
massage, 475–493
contraindications, 479–480
see also specific massage techniques
legal aspects, 479
preparations, 475–479
specific usage, 489–491
lymphoedema (manual lymphatic
drainage massage), 491, 616
techniques (manipulations),
480–486
newer/other, 487–489
see also micromassage
match day
officials, 378
pre-match and pitch-side
considerations, 375
mechanical instability, 288
mechanical noxious stimuli and
nociception, 382
mechanical tension tests
cervical spine, 229
lumbar spine, 220–222
mechanics see biomechanics
mechanosensitivity, 562–563
cause of increases, 566
treatment reducing, 575–576
meconium ileus in cystic fibrosis, 107
medial kinetic rotation test, 208b
medial ligaments (medial collateral
ligaments)
ankle, assessment, 249
knee, assessment, 243–244
medial meniscus tests, 245
medial nociceptive system, 383
median neurodynamic test (MNT)
MNT1, 570–572
MNT2, 572
medical approach to health promotion,
189
medical history, past/previous, 211
amputee, 461t
fractures and, 508
pain patient, 388t
medical insurance and sports
physiotherapy, 372
medical management
brain injury, 599
motor neurone disease, 596–597
multiple sclerosis, 595
stroke, 592
see also drug therapy
medical model of disability, 191
medical record, problem-oriented, 507
Medical Research Council Dyspnoea
Scale, 85t
medication see drugs
medicine ball work, 295
membrane (cell), pulsed shortwave
therapy effects, 442–443
men (males)
infertility in cystic fibrosis, 107
lower urinary tract symptoms, 620

meniscal assessment, 214, 245
menopause, 623
psychosexual issues, 626
Mental Capacity Act (2005), 544b
mental health problems see
psychosocial disorders
mental practice of upper limb
movement following
stroke, 70b
mentoring/mentorship, 50
reflection and, 74–75
meperidine see pethidine
meridian points (acupuncture),
404–407, 409–410
pressure on, 489
metabolic equivalents and exercise
prescription in cardiac
rehabilitation, 156, 158
metabolism (drug), 57, 62
first pass, 62
metacarpal fracture, 512–513
metacarpophalangeal joint
replacement, 528–529
splinting, 512–513, 529
meta-cognition and clinical reasoning,
69
metastases (spread of cancer)
bronchial/lung cancer, 120
massage and risk of, 480
metatarsal fracture, 517
metatarsalgia, Morton’s (Morton’s
neuroma), 249
metatarsophalangeal joint, assessment,
250
metered-dose inhalers (MDIs), 99
metformin, 64
methadone, 60
methotrexate, 64
metoclopramide, 64
microbiology
pneumonia, 111
tuberculosis, 119
microcurrent therapy, 431
micromassage, ultrasound, 437
microthermal modalities of
electrotherapy, 419–420
microwave diathermy, 433–434
midtarsal joint assessment, 248
migraine, acupuncture, 408
mini-tracheostomy, 179–180
MIT-MANUS, 589
mobilisation (mobilisation exercises),
280–284
in cardiac rehabilitation, 159
classes of exercises, 280–284
myofascial, 487–488
neural tissue, 575–576
postoperative
amputation, 463
ankle replacement, 537
hip replacement, 534
knee replacement, 536–537
thoracic surgery, 179
soft tissue injuries, 267–268
sports, 377
mobilisation (myofascial), 487–488
mobiliser muscles, 306, 309
cervical, 319t
glenohumeral joint, 322t
lumbopelvic, 312t
scapulothoracic joint, 321–322
mobility see movements
Modernisation Agency (MA), 46–47
moment (torque), 350–351, 354–360
definition, 350
joint see joint
monochromacity in laser therapy, 445
Monteggia fracture, 511
moral authority (trustworthiness), 6
morphine, 60, 64
mortality (death), coronary heart
disease, 147
Morton’s neuroma, 247
motions see movements
motivation in pain management, 392
motor control of muscle balance, 309
see also sensorimotor control
motor cortex and proprioception, 288
motor function
amputee, difficulties in learning
new skills, 461
cardiac rehabilitation in older
people and, 163
disorders/impairments (due to CNS
damage), 581
in brain injury, 599
in motor neurone disease, 596
in multiple sclerosis, 594
in Parkinson’s disease, 539–540,
541t, 542, 547
see also sensorimotor control
motor nerve stimulation in
interferential therapy,
428–429
motor neurone disease, 595–597
motor units, 309
movement(s) (motions/mobility)
accessory see accessory movements
analysis (biomechanical
perspective), 331–332
development of equipment,
343–344
in gait, 333–338
methods, 342–344
specific joints, 334–338
see also kinematics; kinetics
assessment, 212
ankle/foot, 248–250
Index
fractures, 509
hip joint, 237–240
knee joint, 243–246
neurological patient, 583
shoulder joint, 231–234
spine see subheading below
cervical spine, 318t
assessment, 225–227
dysfunction, exercises dealing with,
286–287
in exercise-based cardiac
rehabilitation, 159
falls during see falls
fractures
abnormal, 497
assessment, 509
limitation, 497
functional see functional tests
inflammation and, 391
neural tissues
treatment addressing, 575–576
versus musculoskeletal tissue,
identifying symptoms due
to see structural
differentiation
Newton’s laws, 344–345
older people, 547–548
transfers, 548
in Parkinson’s disease, 547–548
transfers, 548, 556t
voluntary, dysfunction, 541
pelvic girdle, restriction in
pregnancy, 614
range of see range of movement
resistance to see resistance to
movement
in sensorimotor control
rehabilitation,
development and
enhancement control of,
287–290
speed of (in exercise), change in,
286
spine, assessment
cervical see subheading above
lumbar (in general), 216–219,
237–238
spine, restriction in pregnancy, 614
upper limb see upper limb
in walking see gait
see also mobilisation; motor
function and specific
movements
movement disorders, clinical features,
580–581
see also specific disorders
MRC Dyspnoea Scale, 85t
mucus
in chronic bronchitis, 86
653
 Index
in cystic fibrosis, excess and viscid,
106
drugs breaking down (mucolytics)
asthma, 98b
COPD, 92
cystic fibrosis, 108
see also secretions
multidisciplinary team see team
multifidus, 313, 313f
problems, 314t
multiple crush syndrome, 563
multiple sclerosis, 592–595
muscle, cardiac, drugs increasing
contractions, 57–58
muscle, skeletal
abdominal see abdominal muscles
agonists, 306
antagonists, 306
atrophy/bulk loss, 581
with fractures, 497, 499, 501
progressive, 596
thigh, 241–242
balance
loss see imbalance (subheading
below)
neurophysiological components,
309–311
classification of roles, 306, 307t
contraction see contraction
contractures see contractures
in COPD, loss of mass, 90
damage with fractures, 499
delayed-onset soreness, 273,
276–277
differentiation test, 214–215
dysfunction in neurodynamic tests
median neurodynamic test 1
(MNT1), 570–571
median neurodynamic test 2
(MNT2), 572
prone knee bend, 570
radial neurodynamic test,
573–574
slump test, 567
straight leg raising test, 568
straight leg raising test modified,
569
ulnar neurodynamic test, 573
fascia see myofascia
forces (and their calculation), 355
spine (base), 358–359
upper limb, 356–357
imbalance, 305–330
assessment/examination, 305b,
311–317
definition, 305–306
insertion points (and relevance to
strength evaluation),
364–366
654
length see length spread, 487
as mobilisers see mobiliser muscles trigger points, 488–489
pelvic floor see pelvic floor muscles acupuncture and, 409–410
pull angle (relevance to strength palpation, 229, 231
evaluation), 366 myositis ossificans, 511
reciprocal inhibition, 264, 284 massage contraindicated, 480
re-education in childbearing year, myotome tests
614–615 cervical spine, 228
resisted muscle testing see resistance lumbar spine, 219
to movement
respiratory see respiratory muscles
N
spasm/spasticity see spasm;
spasticity nailing, intramedullary, 504
as stabilisers see stabiliser muscles naloxone, 65
stiffness/tension, 274 naproxen, 65
in Parkinson’s disease National Health Service see NHS
(=rigidity), 541–542, 581 National Institute for Health and
relative, 310–311 Clinical Excellence
stimulation (electrical), in (NICE), 14
interferential therapy, critical care rehabilitation, 143
428–431 National Service Frameworks, 13
see also neuromuscular electrical nature of condition, determination,
stimulation 210
strength see strength nebulisers, 99
stretching see stretch asthma, 99
synergists, 306, 307t COPD, 92–93
tightness, muscle groups prone to, cystic fibrosis, 108–109
214, 225 neck
tone, 274 flexion see flexion
disturbances (neurological flexors see flexors
patient), 581 pain, acupuncture, 408
weakness see weakness rotation see rotation
see also specific named muscles wry, 225
muscle fibre types, 130t, 278–279, need, commitment to assist those in,
279t 5–6
in respiratory muscles, 130 Neer arthroplasty, 525
muscle spindles, 288t, 289f Neer classification of proximal humeral
and proprioception, 287–288 fracture, 510
CNS damage effects, 581 neoplastic disease see cancer; tumours
musculoskeletal system (and nerve(s)
orthopaedics) action potentials, 61, 420–421
assessment see assessment compression see compression
in brain injury, 599 dysfunction
females, 605–608 closing versus opening, 562b
pregnancy, 608–609, 618 extraneural, 562
identifying symptoms due to intraneural, 562
movement of neural tissue progression of treatment, 576
or tissues of see structural electrical stimulation see motor
differentiation nerve stimulation;
older people’s conditions of, 546t transcutaneous electrical
Mycobacterium tuberculosis nerve stimulation
(tuberculosis), 118–119 injury/damage, 561–563
Mycoplasma pneumoniae pneumonia, with acupuncture needles to,
110 406
myelin loss/damage in multiple with fractures, 501
sclerosis, 593 pain relating to (neuropathic
myofascia pain), 386
mobilisation, 487–488 mechanical forces activating see
release, 487 mechanosensitivity

needling (acupuncture) and its
effects on, 409
see also neurodynamics; peripheral
nervous system and specific
named nerves
nervous system see autonomic nervous
system; central nervous
system; peripheral
nervous system;
sympathetic nervous system
networks, professional, 50
neural… see nerve; neurodynamics;
neurological tests
neurodynamics, 561–577
case studies, 577b
neurodynamic assessment/tests,
563–565
contraindications, 563
general tests, 566–567
indications and precautions,
561, 563
interpreting findings,
565–566
lower limb tests, 568–570
upper limb tests, 570–574
neurodynamic treatment, 575–576
neuroendocrine disorders in brain
injury, 598
neurogenic detrusor overactivity, 619
neurogenic response in structural
differentiation see
structural differentiation
neuroimaging, acupuncture research,
407–408
neurological disorders/dysfunction
(CNS), 59, 579–604
assessment see assessment
bladder dysfunction due to,
619
causes, 580
clinical features, 580–582
glossary of terms, 600
drug therapy, 59
interventions, 586–590
lung surgery-related, 173t
older people, 546t
outcome measures see outcome
measures
neurological tests (incl. neural tests)
cervical spine, 228–229
hip joint, 240
lumbar spine, 219–223
neuromatrix theory of pain/
nociception, 384
neuromuscular competence, reduction
leading to respiratory
failure, 134
neuromuscular electrical stimulation
(NMES), 421, 431
neuromuscular system
disease, respiratory muscle failure,
106, 122, 134t
pregnancy, 609
see also muscles; nerves;
proprioceptive
neuromuscular facilitation
neuropathic pain, 386
neuropathies, cranial, in brain injury,
598
neuropathology, Parkinson disease,
542
neurophysiological components of
muscle balance, 309–311
neurotransmitters, 62
Parkinson’s disease, 548
neutral zone concept, 308–309
New York Heart Association functional
classification of heart
failure, 162, 162t
Newton’s laws, 344–345
NHS (National Health Service)
leadership and, 42–43
leadership qualities framework
(LQF), 42, 44
long-term vision (in 2010), 17
loss of public confidence, 8, 10
outcomes framework, 15–16
services see services
NICE see National Institute for Health
and Clinical Excellence
Nintendo Wii, 466
older people, 553
nitrous oxide + oxygen (Entonox) in
labour, 611
NMDA (N-methyl-D-aspartate)
receptors and pain, 385
nociception (nociceptive system), 381
activation, 382–384
case studies, 395–396
targeting in pain management,
390–394
sensitisation see sensitisation
non-invasive ventilation, 135
COPD, 92, 94–95
motor neurone disease, 597
non-small cell lung cancer, 169, 171
non-steroidal anti-inflammatory drugs
(NSAIDs; cyclo-oxygenase
inhibitors), 60–61
adverse/side-effects, 60
tissue repair, 440
COX-2-specific, 60
fracture union time and, 499
in soft tissue injury, 253
non-thermal modalities of
electrotherapy, 419–420,
420f, 434–450
normality, 192, 192b, 196
Index
nosocomial pneumonia complicating
acute respiratory distress
syndrome, 116
numbness after breast surgery, 625
numerical rating scales of pain,
387–388
nutrition/diet
brain injury care and, 598–599
soft tissue healing and, 503
nystagmus, 581
O
oat (small) cell lung cancer, 120t
Ober’s test, modified, 236
obesity and exercise-based cardiac
rehabilitation, 164
objective(s), in goal-setting
(neurological patient),
586, 586t
objective assessment, 212–215
aims, 208
amputee, 463t
fractures, 507–509
femoral shaft, 519–520
muscle imbalance, 311t, 315–317
cervical spine region, 320t
shoulder complex, 323
vastus medialis oblique
imbalance, 308–309
muscle strength, 213
neurological patients, 583
Parkinson’s disease, 546
older people, 546
see also SOAPE process
oblique fractures, 495
oblique muscles, external and internal
(EO/IO), females, 606,
606f
in pregnancy, 609
obliquity, pelvic, 337
observation (look)
fractures, 508
general and local, 212
mother in labour, 610
muscle imbalance, 315–316
neurological patient, 583
obstetrics see pregnancy
obstructive pulmonary disease, 83
chronic see chronic obstructive
pulmonary disease
types, 83
see also specific types
occupation see employment
ocular muscle dysfunction, 581
odansetron, 65
oedema (fluid accumulation)
ankle/foot, 246
fractures, 497, 501
655
 Index

interferential therapy, 429 proprioceptive deficits, 287t of area, 208–209

lymphatic see lymphoedema shoulder arthroplasty, 525 of duration, 209
pulmonary see lungs postoperative routine, 526t with fractures, 508, 520
residual limb following amputation, osteoporosis of severity, 209
464 COPD and, 90–91 breast cancer patients,
see also swelling cystic fibrosis and, 94 postoperative, 624
oesophagoscopy, preoperative, 171 OTTAWA rules, 376 bronchial/lung cancer, 120
oesophagus outcome measures (in interventions/ cardiac see angina
anatomy, 169 rehabilitation), 15 case studies, 395–398
operations, 174 amputation, 469–470 definition, 381, 381b
complications, 174 cardiac rehabilitation, 165t fractures, 497
perforation, 171 low back pain, 225 assessment, 508, 520
repair, 174 neurological disorders, 584–586 hip (as source of pain)
tumours, 171–172, 174 Parkinson’s disease, 552, 553t versus knee, differentiation, 241b
oestrogen(s) older people, 552, 553t versus lumbar spine,
in menopause outpatient differentiation, 218–219,
depletion, 623 amputee, 464t 237–238
in symptom management, 623 cardiac rehabilitation programme knee, referral from hip, 208
in pregnancy, 608 (phase III), 151, 159f, low back and pelvis see low back
oil, massage, 479 164–165 pain; lumbopelvic region;
older people/elderly, 539–559 physiotherapy-led exercise pelvis
assessment, 544–551 programmes after neck, acupuncture, 408
cardiac rehabilitation, 149 intensive care, 143 in neurodynamic tests, 565
exercise-based, 163 ovaries, 607 median neurodynamic test 1
falls see falls overload in muscle strengthening, 274, (MNT1), 570–571
interventions, 551–555 279 median neurodynamic test 2
resistance training, 279–280 overpressures (MNT2), 572
omeprazole, 65 cervical spine, 227 prone knee bend, 570
one (single) compartment model, lumbar spine, 222 radial neurodynamic test,
63 Oxford Scale, 213, 213b, 274–275 573–574
one repetition maximum (1RM), 279 femoral shaft fractures, 520, 520t slump test, 567
onset of condition oxygen consumption (VO2) straight leg raising test, 568
insidious, 210 aerobic exercise, 153–154 straight leg raising test modified,
traumatic, 210 functional exercise testing, 158 568–569
open kinetic chain exercises, 273, 278, oxygen tension, arterial (PaO2), in ulnar neurodynamic test, 573
290 respiratory failure, 133 neurological conditions causing, 581
open reduction, 501 type I failure, 121 multiple sclerosis, 594–595
and internal fixation, 503 type II failure, 121 Parkinson’s disease, 547–548
open wound oxygen therapy older people, 547–548
fractures with, 495 adverse effects/toxicity, 138 physiology/biology, 381–387,
femoral shaft, 515 asthma, 98–102 395–397
laser therapy, 447–448 COPD, 91–92 gate control theory, 391, 407
massage contraindicated, 479 cystic fibrosis, 93 patient education, 392
Operating Framework (DoH), 47 pleuritic see pleurisy
opioids and opiates, 59–60 pregnancy-related, 612–615
P
childbirth, 611 psychological factors see
patient-controlled with, in thoracic pacing of activity in pain management, psychological factors
surgery, 176 393 quality, 387b
receptors, 59–60, 62 pack-years (exposure to smoking risks), assessment, 388
organisations, leaders and their 86b sensitisation see sensitisation
development in, 48–49 paediatrics see children in sensorimotor rehabilitation of
oropharyngeal secretions, removal, 141 pain, 381–401 spine, 294
orthopaedics see musculoskeletal acute versus chronic, 223 shoulder see shoulder
system pelvic area in women, 622–623 social factors see socioeconomic
osteoarthritis amputation, 459–460 status
acupuncture, 408 assessment/measurement, 381–387, temporal aspects, 387b
exercise-based cardiac rehabilitation, 395–397 see also complex regional pain
164 of aggravating and easing factors, syndrome; headache;
knee see knee 209–210 tenderness

656

pain management/relief (analgesia),
390–394
in acupuncture, 404, 407, 409
amputated limb, 459–460
in breast cancer surgery,
postoperative, 624
case studies, 396–398
electrotherapy
interferential therapy, 428
laser therapy, 448
TENS see transcutaneous
electrical nerve
stimulation
in pelvic pain in women, 622–623
pharmacological see analgesic drugs
in pregnancy, 615
in labour, 610–611
in thoracic surgery, 175–176
see also analgesic drugs
palliative care see terminal stages
palpation (feel/touch)
acupuncture points, 405
assessment by, 212
cervical spine, 229
fractures, 509
hip joint, 238
lumbar spine, 222
shoulder joint, 231
in massage, 477–478
panlobular/panacinar emphysema,
86–87, 86b
paracetamol, 60–61, 65
parallel bars, prosthetic-fitted amputee,
466
parasympathetic nervous system, 56
paravertebral block, thoracic surgery, 176
Parkinson disease, 59, 539–559
aetiology and epidemiology, 542
assessment, 544–551
case study, 555b
classification, 542–544
diagnosis, 542
gait, 332–333
interventions, 551–555
neuropathology, 542
symptoms, 540–542
rigidity, 541–542, 581
parkinsonism (Parkinson’s plus), 542,
542t
partial agonist, 62
participation
service user, 194–195
in WHO International Classification
of Functioning, 583
partner as factor contributing to high
quality workforce, 43f
partnership, 193–202
definition, 193–194, 193b
user involvement, 193–202
passive insufficiency of muscles, 214
passive movements/motions
assessment, 212
ankle joint, 248
cervical spine, 227
hip joint, 239
knee joint, 243
lumbar spine, 218–219
neck, 220
shoulder joint, 233
end-feel during, 213
exercises, 280
in acute respiratory distress
syndrome, 116
in soft tissue injury
rehabilitation, 212–213,
264
see also continuous passive motion
passive muscle imbalance, 306
passive neck flexion, assessment, 220,
566
passive physiological intervertebral
movements see
intervertebral movements
passive physiological intervertebral
movements, lumbar spine,
218–219
past medical history see medical history
patella
fracture, 515
taping, 327
vastus medialis oblique imbalance
and the, 325–327
patellar tap, 242
patellofemoral joint assessment,
242–243, 245–246
femoral shaft fractures, 519
patient
assessment see assessment
autonomy, 5
communication see communication
complaints by, 15
compliance with exercise
prescription, 300–301
education see education
feedback, 15
preparation for massage, 478
reflection on interactions with, 77t
reporting of outcome measures, 15
responsibilities to, 6–7
use of term, 1, 183
see also body; client; service user
patient-controlled analgesia, thoracic
surgery, 176
payers of services, responsibility to, 7
peak (expiratory) flow in asthma, 97
measurement, 101
pectoral muscles
smaller (pectoralis minor), 321–322
Index
length test, 231
tightness, 232
Pedotti diagrams, 349
peer review, 16
pelvic floor muscles, female
anatomy/physiology, 606–607
exercise/training, 619–620
biofeedback as adjunct to, 620
post-gynaecological surgery, 622
postnatal, 624
in pregnancy and childbirth, 609,
614
dysfunction, 607, 612
exercise, 624
normal changes, 606–607
re-education, 614–615
restricted movement, 614
pelvic girdle (women)
anatomy, 605–606
in pregnancy
pain (PGP), 612–615
restricted movements, 614
pelvic organ prolapse, 619
pelvis
anatomy, women (incl. pregnancy),
605–608
anterior tilted, 313–316, 314t, 315f
fracture, 513
joint see joints
motion
prosthetic-wearing amputee,
337–338, 466
in coronal plane (=obliquity),
337
in transverse plane (=rotation),
337–338
pain in area of, 622–623
see also lumbopelvic region
perceptual disturbances, 582
percussion (percussive manipulations
- tapotement), 485–486
ventilated patient, 141
percussion note, asthma, 87–88
perineal trauma in labour, 611–612,
618
periosteal proliferation, fracture,
497–498
peripheral nervous system, 561–563
mechanics, 561
in pain, 382, 385
targeting in pain management,
391
pathophysiology, 561–563
see also nerve; neurodynamics
peripheral vascular (arterial) disease
amputation in, 457, 471
exercise-based cardiac rehabilitation
and, 163
peroneal neurodynamic test, 568–570
657
 Index

person-centred practice, 5 sport and, 374–375 pneumothorax, 114–115, 171

personal (individual) behaviour see thoracic surgery and, 177–178 open versus closed, 115
behaviour Physiotherapy Framework (CSP), 9 spontaneous, 114, 171
personal (individual) freedom see picking up (massage), 483 cystic fibrosis, 107, 112
autonomy Piedello’s sign, 219 traumatic, 114–115, 171
personal (individual) model of pilates in pregnancy, 617 ventilator-induced, 138
disability, 190b, pink puffers, 91 poking-chin (forward head) posture,
191–192 piriformis test, 236–237 225, 226f, 319–320
personal (individual) qualities and pitch-side considerations, 375 polarisation
requirements of leaders, pivot shift test, 245 in laser therapy, 445
44, 49–50 placebo effect in acupuncture, 406–409 nerve, 417
pethidine (meperidine), 60, 65 placenta political correctness, 197
childbirth, 611 expulsion, 611 political dimensions of
petrissage, 481–484 growth and function, 608 interprofessional
pH, 62 healing of site, 612 education, 26t
phalangeal fracture planning positional factors affecting symptoms
foot, 517 amputee treatment, 462 (incl. pain), 209–210
hand, 512–513 discharging of patient see discharge positional weakness (muscle), 309–310
phantom limb pain and sensations, disorder of (apraxia), 582 positioning
459–460 fracture management, 507 joint, sensing see proprioception
pharmacodynamics, 62–63 case study with femoral shaft patient, 140
pharmacokinetics, 63 fracture, 522 post-thoracic surgery, 179
pharmacology, 53–65 group exercise, 298 respiratory patient, 140
basic science, 54–57 in muscle imbalance rehabilitation, sputum removal in COPD, 94
defining, 53 317 spinal, stretching exercises and, 283
glossary, 61–65 in reflective practice, 75–76 positive airways pressure (positive
see also drugs see also SOAPE process pressure breathing)
photobioactivation effects of laser plantar flexion, 219–220, 220f, 248, continuous, post-thoracic surgery,
therapy, 446–447 248f–249f, 335 180
photobiomodulation effects of laser plantar response/reflex, 220b intermittent see intermittent positive
therapy, 446–447 plaster (of Paris) immobilisation, pressure breathing
phototherapy, bronchial/lung cancer, 502–503 non-invasive, COPD, 94–95
120 sores, 499 positive end-expiratory pressure
‘physical’, word removed from plasticity, tissue, 261 (PEEP), 136–137
definition of disability, pleura intrinsic (PEEPi), 137–138
192 acupuncture needle injury to, 406 positron emission tomography of lung
physical examination, 224 anatomy, 169 cancer, preoperative, 171
ankle/foot, 246–248 aspiration posterior draw test
fractures, 508t and biopsy for tumours, 120 knee, 244
pain, 396–397 for culture in pneumonia, 111 shoulder, 234
low back, 224 effusions, 113 postnatal period (puerperium), 612
physical exercise see exercise; exercise operations, 174 advice, 614
tolerance; fitness pus collection (empyema), 113–114, postoperative care
physiological movements, assessment, 171 amputation, 463–465, 463t
212 rub, 112 breast cancer surgery, 624–625
intervertebral movements see pleurectomy, 174 gynaecological surgery, 622
intervertebral movements pleurisy (and associated pain), 112 joint replacement
muscle imbalance, 311t bronchial/lung cancer, 120 hip, 534
physiology pneumonia, 111 metacarpophalangeal, 529
pain see pain plyometric exercises, 295–296 shoulder, 526t
women’s (incl. pregnancy), 611 pneumatic post-amputation mobility thoracic surgery, 177
physiotherapists, 1–21 (PPAM) aids, 465 postpartum period see postnatal period
cardiac rehabilitation and, 151–152 pneumonectomy, 171, 173 postural drainage
community, cystic fibrosis, 109 pneumonia (infective), 110–112 bronchiectasis, 105
fractures, 506–510 in bronchiectasis, recurrent, 104 COPD, 94
lower limb amputation and, nosocomial, complicating acute cystic fibrosis, 109
460–461 respiratory distress posture (generally but predominantly
respiratory, 139–141 syndrome, 116 standing)
responsibilities (in general), 1–21 ventilator-associated, 138–139 assessment/examination, 212

658

cervical spine and, 225
hip joint and, 236–237
knee joint and, 241
lumbar spine and, 215–216
muscle imbalance and, 311t
neurological patient, 583
shoulder and, 230–231
in asthma, 96
leg, deformities, 241, 241f
muscles involved in, 307t
muscle fibre types and, 278
older people, 548
Parkinson’s disease, 548
case study of management, 556t
instability, 541–542, 548
poking-chin (forward head), 225,
226f, 319–320
postoperative
amputee, 464
breast surgery, 625
in pregnancy
advice, 614
changes, 608
sway see sway back; sway backwards
and forwards
see also alignment; deformities
potassium-sparing diuretics, 58
potential energy, 360–361
pounding, 486
poverty see socioeconomic status
power (mechanical), 360
angular, 361
joint, during walking, 362
linear, 360
power (pulsed shortwave therapy),
output, 441
power (service user) and empowerment,
195, 200–201
practice
decision-making, 69–71
evidence-based see evidence-based
practice
reflection in see reflection
scope of, 4–5
social interaction and spheres of
influence in, 47–48
standards of see standards
student qualification and key
elements of preparing for,
4 patients), 586
practice-based learning, 32
practitioner as factor contributing to
high quality workforce,
43f
prednisolone, 65
pregabalin, 65
pregnancy, 608–616, 618
anatomy, 605–608
exercise see exercise
musculoskeletal changes, 608–609
physiology, 607–608
sex in, 626
see also childbirth; delivery; labour;
postnatal period
pre-match considerations, 375
preoperative period (care/procedures/
investigations)
amputation, 462–463, 463t
breast cancer, 624
gynaecological surgery, 621–622
hip arthroplasty, 533
thoracic surgery
care, 177
investigations, 171
preseason considerations in sport,
374–375
present condition/complaint, 208–209
amputee, 461t
history of, 210–211
fractures, 508
pressure
on acupuncture meridian points,
489
centre of, 346, 349–350
in-shoe analysis of, 350
massage using, 481–484
pressure biofeedback device/unit, 294,
316
pressure-controlled ventilation, 136
advanced modes, 137
pressure garments and bandages see
compression garments
pressure-supported ventilation, 137
previous medical history see medical
history
PRICE (and PRICEM) principles,
256–260
practical application, 260
sports injuries, 376
see also specific components
primary care
cardiac rehabilitation (in long-term
follow-up/maintenance),
151
exercise prescription, 165
service delivery, 18
problem(s), listing (in goal-setting
with neurological
problem-based learning, 32–33
problem-oriented medical record, 507
prodrug, 63
profession(s)
belonging to one, 7–9
characteristics/description, 3–4
education between see
interprofessional
education
Index
history of, 2–3
networks between, 50
responsibility to the, 7
professional(s)
autonomy, 2, 5
characteristics of being one, 5–6
code of values and behaviour, 8–9
identity, 33–34
responsibilities of being one, 3–7
Rules of Conduct (the Rules), 9
professional development
in cardiac rehabilitation, 152b
continuing see Continuing
Professional Development
professional membership, 8
progesterone in pregnancy, 608
progression
of condition, determining, 210
of exercises, 284–286
in cardiac rehabilitation, 161
proprioceptive exercises, 291
of soft tissue healing after injury, 260
progressive bulbar palsy, 596
progressive multiple sclerosis
primary, 594
secondary, 593
progressive muscular atrophy, 596
proliferation stage (fibrous/phase 3) of
repair (1-10 days),
261–268
factors affecting rate, 261–262
pathophysiology, 262
physiotherapy, 262–265
ultrasound therapy and, 438
pronation, foot, 243, 247, 247b
prone knee bend, 221, 570
propofol, 65
proportional assisted ventilation, 137
proprioception, 287–290
assessment, 289–290
ankle, 248
knee, 245
deficiencies (and associated
conditions), 287–288, 287t
neurological disorders, 581
definition, 274, 287b
mechanism, 288
muscle balance and, 309
rehabilitation, 287–290
Parkinson’s disease, 555t
proprioceptive neuromuscular
facilitation, 284
prose, reflection in, 78–79
prostheses (amputees), 465–468
assessment, 461t, 464t
of gait, 461t
gait deviations, 468–469
management before fitting of, 463t,
465
659
 Index

outcome measures, 469–470 in pulsed shortwave therapy ramipril, 65

physiotherapy management with duration/width, 441 range of movements
after fitting, 465–467 repetition rate, 441 assessment/measurement, 212–213
before fitting, 465 in TENS, 421, 423–424 ankle, 248, 334
transfemoral, 469f pulsed shortwave therapy, 440–444 hip, 239
both limbs, 471 pulsed ultrasound, 437 knee, 243, 341
transradial, 471f low-intensity, and fracture healing, exercises increasing, 280–282,
transtibial, 468f 439–440 284–286
prostheses (joint - also called pursed-lip breathing, 88, 89f fractures causing limitation, 497
implants) purulence see pus formation soft tissue injuries, exercises, 264
lower limb, 532 pus, pleural (=empyema), 113–114, 171 reaching task, kinematics, 338–340
hip, 534 reaction see action–reaction; ground
knee, 536 reaction forces
Q
upper limb, 525 rearfoot (hindfoot) examination, 247–248
shoulder, 525, 526t Q angle, 241f, 243, 326 reasoning, clinical see clinical reasoning
protection (in PRICE principles), 257 qi and acupuncture, 404–405 receptors
sports injuries, 376 quadrant tests agonists, 62
psychological factors, pain, 386 hip, 240 antagonists, 62
case studies, 395, 397 knee, 246 as drug targets, 55f
low back, 224 shoulder, 233 inverse agonist, 62
psychological treatments, pain, 392 quadratus lumborum partial agonist, 62
psychosexual issues, 626–627 assessment, 237 in proprioception, 287b
psychosocial disorders (mental health problems, 314t reciprocal inhibition (technique), 264,
issues) quadriceps, loss of bulk, 242 284
older people, 546t, 551 quadriceps reflex, 220, 221f record(s), medical, problem-oriented,
postpartum risk, 612 qualifications in sports physiotherapy, 507
psychosocial impact 369–374 rectal disorders, 621
amputation, 458–459 Quality Assurance Agency, 27 rectus abdominis, females, 606, 606f
in coronary disease of exercise quality assurance standards, 9, 14 in pregnancy, 609
training, 153t quality of life as outcome measure in diastasis, 615
cystic fibrosis, 107–108 neurological patients, re-education, 614–615
exercise training in health and in 585t rectus femoris
coronary heart disease, question(s), initial (in assessment), restriction, versus iliopsoas
153–154 208 restriction, 236
lymphoedema, 626 see also history-taking; interview stretch, 283
see also biopsychosocial assessment red flags, 389
psychosocial interventions in cardiac low back pain, 224b
R
rehabilitation, 148–149 reduction (of fracture), 501–502
pubertal delay in cystic fibrosis, 107 radial neurodynamic test, 573–574 open see open reduction
pubic bone radiofrequency therapies, 433–434 re-education see retraining/re-education
ramus fracture, 513 radiology see imaging and specific (muscles)
symphysis see symphysis pubis modalities reflection, 6, 11, 16, 50, 67–81
public health and its promotion, 200 radionuclide scan of bone, records of defining, 67–69
history, 199 previous scans, 211 as form of assessment, 71–72
puborectalis, 620 radiotherapy, 625 in practice, 16, 16b
pudendal nerve, 607 breast cancer important principles, 75–78
puerperium see postnatal period adjuvant, 624 methods, 78–80
pull (muscle), angle of, 366 care following, 624 process of, 72–75
pull test, Parkinson’s disease, 541–542 bronchial/lung cancer, 105 rationale, 68–69
pulmonary embolism with fractures, radius requirements, 71
499 amputation through, prosthesis, reflex(es)
pulmonary tissue/organ see lung 471f spinal
pulse (arterial) arthroplasty of head, 530f cervical, 228
in asthma, 96 fractures, 511–512 lumbar, 220
exercise raising, in cardiac distal, 497, 504, 511–512, 512f proprioception and, 288
rehabilitation, 159 see also Colles’ fracture; stretch, in ballistic stretching, 282
leg, 246 Smith’s fracture reflex sympathetic dystrophy see
pulse (electrotherapy) head, 511 complex regional pain
frequency see frequency proximal, 511 syndrome

660

refugees, disabled, 188
registration (with Health Professions
Council), 7
regulations see legal issues
rehabilitation
back, programme, 225
cardiac (in cardiovascular incl.
coronary disease),
147–168
definition, 148–150
exercise training in see exercise
outcome measures, 165t
pathway, 166f
patient groups and special
populations, 149–150,
162–164
phases/components, 150–152,
164–165
provision and cost-effectiveness
in UK, 150
research evidence, 148–149
team, 151, 152f
critical care patient, 141
exercise in see exercise
functional, 286
joint replacement
ankle, 537
hip, 534–535
knee, 536–537
muscle imbalance
transversus abdominis, 317t
vastus medialis oblique, 327
neurological, 586–590
assessment for see assessment
multiple sclerosis, 593b, 595
outcome measures see outcome
measures
stroke, 592
outcome measures see outcome
measures
pulmonary (in chronic respiratory
disease), 93, 102
asthma, 102
COPD, 93
definitions, 93b
sensorimotor see sensorimotor
control
relapsing–remitting multiple sclerosis,
593
relationships (between people),
183–205
changing dynamics, 193–202
context, 188–193
relaxation
asthma, 103
with inhalers, 102
pain management, 393, 393b
relaxin, 616
remifentanil, 60
remodelling, bone, 498
remodelling stage (phase 4) of repair
(10+ days), 261–268
case study, 396–398
factors affecting rate, 261–262
pathophysiology, 265–266
physiotherapy interventions,
266–268
ultrasound therapy and, 438–439
renin–angiotensin system, 58
repair see healing and repair
repeated movements
cervical spine, 227
lumbar spine, 217
repetition number in exercises, 279
plyometrics, 296
see also DRIFT
repolarisation, nerve, 417
reproductive (genital) tract
female, anatomy and physiology,
607
prolapse, 619
see also urogenital dysfunction
re-registration, 8
research
acupuncture, 406–410
evidence, 10–13
cardiac rehabilitation, 148–149
resistance to movement
exercises (resistance training),
278–280
in cardiac rehabilitation,
161–162
special patient groups, 279–280
testing, 212
shoulder joint, 233
resisted contractions, symptoms arising
from, 213
respiratory disease/disorders, 83–127
chronic, pulmonary rehabilitation
see rehabilitation
exercise-based cardiac rehabilitation,
164
lung surgery-related, 173t
older people, 546t
see also lung
respiratory distress syndrome, acute see
acute respiratory distress
syndrome
respiratory failure (ventilatory failure),
121–122, 133–135
type I, 121–122, 133
type II, 121–122, 133–134
respiratory failure
mixed, 134
pathways to/causes of, 134–135
respiratory infections
in bronchiectasis, control, 105
in COPD, control, 91
Index
in cystic fibrosis, 106, 108
management, 108
see also pneumonia; tuberculosis
respiratory mechanics, 130–131
respiratory muscles (ventilatory
muscles), 129–131
accessory, 129
failure/dysfunction/weakness,
causes, 134
COPD, 132
fatigue, 132–133, 135
training, 93–94
respiratory physiotherapist roles,
139–141
respiratory syncytial virus, 110
responsibilities, 1–21
rest
in PRICE principles, 257–258
sports injuries, 376
tremor at, Parkinson’s disease, 540
restricted movements of spine and
pelvic girdle in pregnancy,
614
restrictive pulmonary disease, 83,
110–117
types, 83
see also specific types
resuscitation, sports, 369–370
retraction, cervical spine, 318t
retraining/re-education (muscles)
in muscle imbalance, 312t
pregnant women, 614–615
retropatellar adhesions with femoral
shaft fractures, 522
retropulsion test, Parkinson’s disease,
541–542
revascularisation
coronary, 158
cardiac rehabilitation after,
149–150
fracture site, 499
rheumatoid arthritis
exercise-based cardiac rehabilitation,
164
hand arthroplasty, 525
management
acupuncture, 408
laser therapy, 448
rhomboids, 321–322
rhythm, massage practitioner’s,
practice, 476
rib pain (flare), antenatal, 615
rigidity in Parkinson’s disease,
541–542, 581
riluzole, motor neurone disease, 597b
robotics, 589
Rolfe model of reflection, 80
rolling, 484
fascial lifting and, 487
661
 Index

rotary component of muscle force, 355 scarf test, 232 multiple sclerosis, 594
rotation scintigraphy (radionuclide scans), phantom limb, 459–460
cervical/neck, 227, 318t bone, records of previous series elastic component and
hip joint, 239 scans, 211 plyometrics, 295
pelvic, 337–338 scope of practice, 4–5 serotonin (5-HT), 61
prosthetic-wearing amputee, 466 Scottish Intercollegiate Guidelines serratus anterior, 321–322
shoulder joint/complex, 219, 232b, Network, 14 service(s)
321t second impact syndrome, 373–374 clinically and cost-effective, delivery,
see also FABER test secretions, respiratory/bronchial (incl. 18
rotator cuff sputum) evaluation, 14–16
actions/forces, 322 as clinical feature leadership and
deficiencies/weakness, 232, in bronchiectasis, 104 delivery of services, 45
322–323 in COPD, 88 improvement of services, 45–47
Rotocaps, 99 in cystic fibrosis, 106 in primary and community care,
Royal Charter, 2–4 management (incl. control and delivery, 18
Rules of Professional Conduct (the clearance of lung fields) quality assurance standards for
Rules), 9 in asthma, 102–103 delivery of, 8
in bronchiectasis, 105 responsibility to those paying for, 7
in COPD, 91, 94 world-class, commissioning of,
S
in cystic fibrosis, 109 45–47
sacroiliac joint assessment, 219 in pneumonia, 112 service user, 193–198
sacroiliac ligaments, assessment, 212, postoperative (after thoracic involvement, 193–198
219 surgery), 178–179 definition, 197b
sacroiliac/trochanteric belt (n in respiratory failure, 122 use of term, 1, 183
pregnancy), 614 ventilated patients, 140 see also client; patient
safe environment for reflection with see also mucus; oropharyngeal setting direction, 45
supervisor or mentor, 75 secretions setting goals see goals
safety issues, acupuncture, 406 see-saw, 350–351 severity
sag sign, 245b segment (body) angle/inclination of injury
sagittal plane, hip joint movement in, calculation, 333–334 and progression through healing
336–337 forces and moments acting on, 354 continuum, 260
SAID (Specific Adaptation to Imposed joint moment and, 364 and rate of healing in stages of
Demand) principle, 305, segmental resection of lung, 173 proliferation and
314 self-efficacy, 389, 392b remodelling, 261–262
salbutamol, 65 self-report pain measures, 387–388 of symptoms, assessment, 208–209
asthma, 98 senna, 65 sexual dysfunction
COPD, 92 sensing of joint position and brain injury, 599
salmeterol, 92 movement see psychological issues, 626–627
Sandwell Integrated Language and proprioception shaking (massage), 484
Communication Service sensitisation of nociceptive/pain shared learning, 24, 26t
(SILCS), 195 system, 385–387 shifted posture (and lumbar spine),
saturation kinetics, 63 case studies, 395–397 216
scaphoid fracture, 512 management strategies targeting, shock, fractures, 497, 499
scapula 390–394 shockwave therapy, 448–450
fracture, 510 sensitizing manoeuvres (in shortwave therapy
movement faults and their neurodynamic tests), pulsed, 440–444
management, 306–309, 564–565 shortwave diathermy, 433–434
324t slump test, 567 shoulder (shoulder joint and complex),
winging, 231, 324t straight leg raising test, 568 227, 230–235, 320–325
scapulohumeral joint, 323t sensorimotor control, rehabilitation, arthroplasty, 525–526
scapulohumeral rhythm, 231–232, 287–290 assessment, 227, 230–235
232f, 320–321 limbs, 291–293 clinical presentations, 323–325
scapulothoracic joint, muscle acting on spine, 293–294 dislocation, 268b
(and muscle imbalance), see also motor control exercises, 285, 286f
321–322 sensory cortex, primary, persistent pain arthroplasty for osteoarthritis,
scar and, 394 postoperative, 526t
breast surgery-related, 624–625 sensory disturbances, 581 thoracic surgery, postoperative,
contractures and, 267 brain injury, 599 179
formation, 262 massage and, 480 fractures in area of, 510

662

impingement see impingement
linear displacement of hand during
reaching with and without
dysfunction of, 339
muscle imbalance and the,
320–325
pain, 69–71, 323
with bronchial/lung tumours,
120
shoulder girdle movements, 231
shuffling gait, 332–333
shuttle walking test, 158
side-flexion
cervical, 227
lumbar, 217–218
SIGAM (Special Interest Group in
Amputee Medicine)
algorithm, 469
SIGN (Scottish Intercollegiate
Guidelines Network), 14
signs (clinical), definition, 208b
simian posture, Parkinson’s disease,
542
simulated learning, 32
simvastatin, 65
SIN factor (severity/irritability/nature)
determination, 210
single compartment model, 63
sinusitis in bronchiectasis, chronic,
104
sit-to-stand test, 297
sitting flexion, assessment, 219
skeletal muscle see muscle, skeletal
skeletal traction, 506b
skills (specific to profession/not shared
by others), 16–17
possessing, 4–5
sports physiotherapy, 369–374
skin
care in lymphoedema, 626
infections
lymphoedema and
predisposition to, 626
massage and, 479
plaster sores, 499
sensory disturbances see sensory
disturbances
traction, 500
sleep and breathing, 122
slider treatment (nerves), 575–576
slow-twitch (type I) muscle fibres, 130,
278, 279t, 317
slump test, 222, 567
small cell lung cancer, 120t
SMART goals, 215
functional tests, 297b
neurological patient, 586
orthopaedic patient, 509
Smith’s fracture, 511
Index
smoking, 189 spasticity, muscle, 276b, 581, 594
behavioural interventions, 189, in multiple sclerosis, drug therapy,
200–201 595
COPD, 84 spatial parameters
chronic bronchitis, 85 gait, 332
coronary heart disease, 147 measurement, 343
emphysema, 87 Special Interest Group in Amputee
exposure to risk, 86b Medicine (SIGAM)
fracture union and, 499 algorithm, 469
lung tumours, 119 special needs groups, cardiac
SOAPE (subjective, objective, analysis, rehabilitation, 149
plan and evaluation) Specific Adaptation to Imposed
process in muscle Demand (SAID) principle,
imbalance, 305, 314 305, 314
cervical spine and, 320, 320t speech problems, neurological
fractures, 507 conditions causing, 582
shoulder complex and, 323 speed
vastus medialis oblique imbalance, of movement (in exercise), change
308–309 in, 286
see also individual components of muscle contractions, effect,
social care and health care, 366–367
collaborative, 23–39 spheres of influence, 47–48
social change approach in health sphincters, anal, and faecal
promotion, 201 incontinence, 620
social difficulties see psychosocial spinal boards, 375–376
impact spinal cord
social history pain mechanisms, 382, 385
amputee, 461t targeting in pain management,
fractures, 508 391–392
social interaction, 47–48 spinal muscle in pregnancy,
social learning theory, 35 re-education, 614–615
social models spine
of communication, 183–184 assessment, 215–229
of disability, 190b, 192–193, cervical see cervical spine
195 lumbar see lumbar spine
socioeconomic (social and/or muscle imbalance and the, 317–320
economic) status muscle and joint forces on base of,
definition, 188b calculation, 358–359
health inequalities and, 188–190 in pregnancy, 608–609, 612–613
pain and, 386–387 pain, 612–613
case studies, 395, 397 restricted movements, 614
low back, 224 reflexes see reflexes
see also entries under psychosocial sensorimotor rehabilitation,
sodium in sweat, cystic fibrosis, 107 293–294
soft tissue stability, 306–308
cervical spine area, palpation, in stretching exercises, position, 283
229 spinothalamic tract and pain
injury, 255 transmission, 382
ankle see ankle spiral fractures, 495
healing and repair see healing spirometry
and repair COPD classification, 85t
laser therapy, 448 incentive, 179
severity see severity splints, metacarpophalangeal joint,
plasticity, 261 512–513, 529
soreness of muscle, delayed-onset, 273, sports (incl. leisure sports/activities and
276–277 athletes), 369–379
sounds of breathing see auscultation cardiovascular and musculoskeletal
spasm, muscle, 273 fitness, 258b
with fractures, 497 energy costs, 156t
663
 Index
functional testing of shoulder joint,
233
in pregnancy, 617
qualifications and skills, 369–374
role of physiotherapist, 374–375
sputum see secretions
squamous cell lung carcinoma, 120t
squats, 285, 327
end-range, 327
squeeze test (calf), 250
stabiliser muscles, 306
cervical, 319t
core, 317
glenohumeral joint, 322t
lumbopelvic, 312t
scapulothoracic joint, 321–322
Stabiliser pressure biofeedback device,
294
stabilising component of muscle force,
355
stability
assessment, 306–309
lumbopelvic, 222, 314–315, 606
shoulder, 234
core see core stability
exercises involving re-education of
spinal and pelvic stability
in pregnancy, 614–615
prosthetic-wearing amputee, 466
see also instability
stance, massage practitioner’s, 475
stance phase in gait, 499–500, 506
standard(s), 7, 13
quality assurance, 9, 14
see also Core Standards
Standards of Proficiency for
Physiotherapists, 7
standing
muscle imbalance, observation, 315
neurological patient observed in and
moving to or from, 583
posture in see posture
shoulder flexion exercise, 285
on toes (myotome S1 test), 220f
standing flexion sign, 219
Staphylococcus pyogenes, 110
static equilibrium, 345
static splints, metacarpophalangeal
joint replacement, 529
static stretching, 282–283, 284b
statins, 58
step
length, 332
time, 332
step test, Chester, 158
stereotypes, 197
sternal foramen, acupuncture needling
through, 406
sternoclavicular joint assessment, 233
664
sternotomy, median, 172 stretch reflex in ballistic stretching, 282
steroids (corticosteroids; stride
glucocorticoids), 58–59 length, 332
adverse effects, 92 Parkinson’s, 549t
asthma, 58–59, 98 time, 332
bronchiectasis, 105 stroke (cerebrovascular accident),
COPD, 92 590–600
multiple sclerosis, 595 clinical features, 591–592
stigma, 197 haemorrhagic, 591
stools see defaecation; faeces ischaemic, 591
stork test, 219 management/interventions, 592
straight leg raising test (SLR; Lasègue’s UK guidelines, 580
test), 220–221, 568 upper limb movements see
historical aspects, 561 upper limb
indications, 568 virtual reality, 588
modifications, 568–570 pathology, 591
structural differentiation, 568 risk factors, 598t
technique, 568 stroking (massage practitioner’s),
upper limb equivalent (of cervical 480–481
spine), 229 practising, 477
strapping, 209–210 structural barriers to disability, 192
buddy, finger fractures, 502 structural differentiation manoeuvre,
streamlining (hydrotherapy), 300 563
strength (muscle) median neurodynamic test 1
assessment/testing, 213, 274–275, (MNT1), 571–572
362–368 median neurodynamic test 2
ankle/foot, 248 (MNT2), 572
fractures, 509, 520, 520t neurogenic response in
hip, 239 abnormal, 565–566
muscle imbalance and, 311t normal, 565
upper limb, 362–368 passive neck flexion, 566
exercises/training/rehabilitation, peroneal neurodynamic test, 570
274–280, 362–368 prone knee bend, 570
amputee, 464 radial neurodynamic test, 574
benefits, 275–276 slump test, 567f
in muscle imbalance, 312t straight leg raising test, 568
upper limb, 362–368 sural neurodynamic test, 570
in water, 299–300 tibial neurodynamic test, 570
as outcome measure in neurological ulnar neurodynamic test, 573
patients, 585t structural instability, 288
‘strength’ window for electrotherapy, 419 students, 23–26
Streptococcus pneumoniae pneumonia, interprofessional learning led by, 33
110 key elements of preparing for
streptokinase, 65 practice on qualification,
stress (fatigue) fracture, 496 4
foot, 517 subacromial structures, testing, 232
tibia, 516 subarachnoid haemorrhage, 591–592
stress tests, musculoskeletal subcutaneous emphysema, 115
ankle ligaments, 248–249 subjective assessment, 208–211
knee, 243–244 aims, 208
stress urinary incontinence, 619 amputee, 461t
stretch (and stretching), 281–284 fractures, 501, 508
in cardiac rehabilitation, 159 muscle imbalance, 311t, 314–315
contraindications, 278 cervical spine region, 320t
definition, 274 shoulder complex, 323
prolonged, causing weakness, 309 vastus medialis oblique,
in soft tissue injury rehabilitation, 308–309
264 neurological patient, 583
teaching, 277–278 Parkinson’s disease, 546

older people, 546
see also SOAPE process
subtalar joint assessment, 248–249
subthermal modalities of
electrotherapy, 419–420
suction, 140
ventilated patients, 140
COPD, 95
Sudeck’s atrophy see complex regional
pain syndrome
sulcus test, shoulder, 234
supervisor, reflection with, 73–75
supination, foot, 247, 247b
supine lying, hip examination, 236
supracondylar fracture of humerus, 510
supraspinal structures see brain
supraspinatus (lesion) test, 235
sural neurodynamic test, 568–570
surgery
breast cancer, 623
bronchial/lung cancer, 120,
169–171
bronchiectasis, 105, 171
cystic fibrosis, 110
gynaecological, 621–622
pyschosexual problems, 626
heart valves, 150
pneumothorax, 171
recurrent, 115
thoracic see thoracic surgery
tuberculosis, 119
see also postoperative care;
preoperative period and
specific techniques/
procedures
swallowing difficulty (dysphagia), 582
multiple sclerosis, 594
Swanson finger arthroplasty, 528, 531f
sway back (abnormal), 216
sway backwards and forwards
(normal), 346
sweat test, cystic fibrosis, 107
swelling
fluid accumulation causing see
oedema
knee, 241–242
limb elevation with, 259–260
swing phase in gait, 334–336,
341–342, 359–360
time, 332
Swiss ball exercises proprioception,
293
symmetry in gait, 332
sympathetic nervous system, 56
pain and, 223
symphysis pubis in pregnancy,
608–609
diastasis, 613
dysfunction (SPD), 613–614
symptoms
aggravating and easing factors,
assessment, 209–210
area of, assessment, 208–209
definition, 208b
duration, assessment, 209
exercise training in chronic heart
disease and its beneficial
effects on, 153t
hip and lumbar spine as source of,
differentiation, 218–219,
237–238
in resisted contractions, 213
severity of, assessment, 208–209
time factors, 210
see also specific disorders
systematic reviews, 11
T
tactile acuity training, 394, 394b
talofibular ligament injury, anterior,
246, 257b
tamoxifen, 65, 624
taping, patella, 327
tapotement see percussion
task-specific practice with neurological
patients, 586–587
teaching (patient) see education
team, multidisciplinary
amputation and, 458b
cardiac rehabilitation, 151, 152f
fractures and, 509–510
reflection on interactions with, 77t
team doctor (sports), 377–378
technology and interprofessional
education, 31
temperature, ankle/foot, 246
see also cryotherapy; ice burns; ice
massage and entries under
thermal
temporal parameters see timing
ten repetition maximum (10RM), 279
tenderness
ankle/foot, 246–247
knee, 242
tendon(s)
differentiation tests, 214–215
injury, eccentric exercise, 277,
301
tendon reflex, Achilles, 220, 221f
tendonitis, Achilles, frictions in, 491
tennis elbow, 491, 577
TENS see transcutaneous electrical
nerve stimulation
tension, mechanical see mechanical
tension tests; muscle
tension headache, acupuncture, 408
tensioner treatment (nerves), 576
Index
terbutaline, 65
asthma, 98
terminal stages (and care incl.
palliation)
COPD, 95
cystic fibrosis, 108, 110
motor neurone disease, 597
tetanus risk, fractures, 499
texture assessment in massage, 477
therapeutic use exemptions (TUEs),
370
therapeutic window
drugs, 424
electrotherapy, 223, 418–419
therapy see treatment
thermal effects of non-thermal
electrotherapy
pulsed shortwave therapy, 442
ultrasound, 437
thermal modalities of electrotherapy,
419, 420f, 432–434
general principles, 432
therapeutic effects, 432–433
see also subthermal modalities
thermal noxious stimuli and
nociception, 381
thiazide diuretics, 58
Thomas test, 236
Thompson’s hemiarthroplasty, 514f
Thompson’s squeeze test, 250
thoracic spine, flexion in slump test,
567
thoracic surgery, 169–181
incisions/approaches, 171–172
indications, 169–171
modalities of physiotherapy,
178–180
pain control, 175–176
physiotherapist and, 177–178
postoperative care, 177
preoperative period see preoperative
period
thoraco-laparotomy, left, 172
thoracoscopic incisions, video-assisted,
172
thoracotomy
anterolateral, 172
posterolateral, 171–172
thorax (chest)
anatomy, 169
deformed shape
COPD, 88
cystic fibrosis, 107
drains, 174–175
expansion exercises (lung
re-expansion)
COPD, 94
pneumonia, 112
pneumothorax, 115
665
 Index
mobility in bronchiectasis,
decreasing, 104
X-ray see X-ray
thoughts and their potential impact on
pain, 388–389
clinicians, 389b
360° feedback, 50
thrombolysis, stroke, 592
thrombosis, venous see venous
thrombosis
thumb, carpometacarpal joint fracture,
513
tibial fracture, 502f, 504f, 515–516
condylar, 515
fixation, 504
healing
low-intensity pulsed ultrasound,
440
shaft, 502f
tibial level amputation
gait deviations, 468
knee contractures, 464
prosthesis, 468
tibial neurodynamic test, 568–570
tibial prosthetic component in knee
arthroplasty, 536
tibiofemoral joint
inferior, accessory movements,
249
superior, accessory movements, 246
tenderness, 242
tibiofibular joint, superior, accessory
movements, 246
timing (temporal parameters incl.
duration and frequency)
of assessment, 207–208
electrotherapy, 419
in interferential therapy, 429
in pulsed shortwave therapy,
pulse duration, 441
in exercise training see FITT
principle
fracture healing and union,
498–499
gait, 332–333
methods of measuring temporal
parameters, 343
of pain, 387b
in reflective practice, 76
stroke management, 592
of symptoms, 209–210
tiredness see fatigue
tissue
healing and repair see healing and
repair
heating in non-thermal
electrotherapy see thermal
effects of non-thermal
electrotherapy
666
in laser therapy
interactions with laser, 446–447
light absorption, 446
pain and threat to, 381
plasticity, 261
shockwave therapy effects, 448
in ultrasound therapy
US absorption and attenuation
by, 436–437
US transmission through tissues,
436
see also soft tissue
toe(s)
clubbing see clubbing
examination, 248
movements, 248
standing on (myotome S1 test),
220f
toe off, 332, 336, 341, 348
tone see muscle
torque see moment
torticollis, 225
touching see palpation; tactile acuity
training
traction, 506
femoral shaft fracture, 515
skeletal, 495
skin, 500
traditional Chinese medicine see
Chinese medicine
training, formal, reflection on
attending, 77t
tramadol, 60, 65
trampette, 295f
transcutaneous electrical nerve
stimulation (TENS), 391,
421–424
acupuncture (low TENS), 423
machine parameters, 421
mechanism of action, 422–423
in pregnancy, 610–611
labour, 615
thoracic surgery, 176
transfemoral amputation see femur
transfer movements
older people, 548
Parkinson’s disease, 548, 556t
transient ischaemic attack, 593
transplants, heart, cardiac
rehabilitation, 149
transporters as drug targets, 55f
transradial amputation, prostheses,
471f
transtibial amputation see tibial level
amputation
transudative effusions, 113
transverse fractures, 495
transverse plane, pelvic motion in,
337–338
transversus abdominis (TrA), 312–317
in pelvic floor muscle training,
619–620
in pregnancy, 609
trapezium replacement, 531f
trapezius, 321–322
trauma (traumatic injury)
acupuncture-induced, 406
ankle (incl. soft tissue), 246, 257b,
261b, 264b, 270b
brain see brain
fracture caused by, 496
fracture causing
to blood vessels and nerves, 501
to viscera, 500
hamstring see hamstrings
head see head
limb amputation following, 457,
470
massage and, 480
onset of condition related to, 210
perineal, in labour, 611–612, 618
pneumothorax, 114–115, 171
proprioception in prevention of,
287b
proprioceptive deficits, 287t
severity see severity
soft tissue see soft tissue
tendon, eccentric exercise, 277, 301
see also burns; fractures
treadmill training, 587–588
treatment
previous, asking questions about,
211
timing of assessment in relation to,
207–208
tremor, 581
Parkinson’s disease, 540, 542
dominant or non-dominant, 543
Trendelenburg test, 238
triceps reflex testing, 228, 229f
tricyclic antidepressants, 61
trigger points see myofascia
trimalleolar fracture, 516
Trinity Amputee Prosthetic Evaluation
Scale, 470
trunk, amputee
assessment, 461t
lateral bending with prosthesis,
468–469
trust and trustworthiness, 6–7
in reflecting with supervisor or
mentor, 74–75
truth in reflection with supervisor or
mentor, 75
tuberculosis, 118–119
tumour(s)/neoplastic disease
amputation due to, 470
lung see lung

malignant see cancer
massage contraindications, 480
oesophageal, 171–172, 174
Turbohaler, 99
turbulence in water, 300
twisting forces, fracture due to, 496
two compartment model, 63
two-pole interferential therapy,
426–427
U
ulnar neurodynamic test, 573
ultrasound therapy, 435–439
clinical uses, 437
fractures, 499
dose, 439
tissue repair and see healing and
repair
union of fractures
delayed/faulty/failure, 500
factors affecting, 499
upper limb (arm)
amputation, 470–471
causes, 457, 458t, 470
levels, 458t
see also amputation
arthroplasty, 525
fractures, 510–513
function as outcome measure in
neurological patients,
585t
joint forces, calculation, 356–357
lower limb (and leg), proprioceptive
exercises, 292–293
moments, 354
movements, following stroke
constraint-induced movement
therapy, 588
mental practice following stroke,
70b
robotics, 589
muscle
forces, calculation, 356–357
strength testing and training,
362–368
neurodynamic tests, 570–574
pain with bronchial/lung tumours,
120
plyometrics, 295–296
reaching motions, 339
tension test, 229
urge incontinence, 619
urinary incontinence, 580–582
multiple sclerosis, 594
psychosexual issues, 627
traumatic brain injury, 599
women, 618–619
obstetrically-related, 607, 612, 618
urinary tract symptoms (lower) in
men, 620
urine, drug excretion in, 57
urogenital dysfunction, 618–620
users of services see service user
uterus, 607
contractions see contractions
V
vaccination, tuberculosis, 119
vacuum extraction, 611
vaginal delivery see delivery
valgus deformities
foot, 247–248
knee (genu valgum), 241, 515
valgus stress test, knee, 243–244
values, professional, code of, 8–9
valves (heart) surgery, 150
varus deformities
foot, 247–248
knee (genu varum), 241
varus stress test, knee, 244
vasculature (blood vessels)
acupuncture needles injury to, 406
amputation due to disease of, 457,
471
with fractures
injury to, 501, 514, 516
supply affecting time to union,
499
in inflammation and injury and its
repair, 256, 261
see also cardiovascular system;
circulation; peripheral
vascular disease;
revascularisation
vastus lateralis, 325
vastus medialis oblique and its
imbalance, 306–309
vaulting, transfemoral amputee, 469
velocity (in gait), 332
angular see angular velocity
linear see linear velocity
venous thrombosis risk
with fractures, 510–517
deep, 499
ventilation, 129–145
mechanical/supported/assisted,
135–139
complications, 137–139
COPD, 92, 94–95
goals, 135
historical background, 135
modes, 136–137
motor neurone disease, 597
physiotherapist’s role, 139–140
thoracic surgery patient, 180
weaning, 141–142
Index
spontaneous, 129–133
opposing forces, 131–132
see also breathing
ventilatory failure see respiratory failure
ventilatory muscles see respiratory
muscles
verbal reflection, 78
vertebral artery testing, 227–228
vertebrobasilar insufficiency and
vestibular symptoms,
differentiation test,
227–228, 227b
vertebrobasilar testing, 228
vertical forces, 345
in gait cycle, 346
lower limb (knee), 355
upper limb, 357
vestibular and vertebrobasilar
insufficiency symptoms,
differentiation test,
227–228
vibrations
in massage, 486
in ultrasound therapy, 435–436
victim-blaming, 199, 199b
video-assisted thoracoscopic incisions,
172
video recordings
amputee rehabilitation, 470
muscle imbalance, 325
video vector generators, 350
virtual reality, 588
visceral injury, fracture causing, 500
visual analogue scale (VAS) of pain,
209, 387–388
case studies, 396–397
visual disturbances, neurological
conditions causing, 581
multiple sclerosis, 594
visual input
as cues in Parkinson’s patients, 555t
in proprioceptive exercises, 291
volume-controlled ventilation, 136
volume of distribution, 63
volume reduction surgery, lung, 173
voluntary movements in Parkinson’s
disease, dysfunction, 541
volutrauma, ventilator-induced, 138
W
walk mat systems, 343
walking
aids, 257
amputee, 465
amputee, 466
aids, 465
bilateral prostheses, 471
incremental programme, 164, 165t
667
 Index
lower limb joints in, 359–360
knee kinematics, 340–342
moments, 359–360
power, 362
moments around ankle/knee/hip
joints in, 359–360
older people, 549
Parkinson’s disease, 549
recovery in treadmill training,
587–588
see also gait
walking tests, shuttle, 158
war, amputations, 458
warfarin, 65
warm-up, exercise-based cardiac
rehabilitation, 159
water, as massage medium, 479
water-based/aquatic exercises
(hydrotherapy), 299
pregnancy, 617
wax therapy, 433
weakness (muscle), 581
CNS damage causing, 581
positional, 309–310
rotator cuff, 232, 322–323
stretch, 309
weaning from ventilation, 141–142
wedge resection of lung, 173
weight, 345
weight-bearing
amputee, 465–466
hip replacement, 534
weight-lifting and muscle insertion
points, 366
weight-transference, amputee, 466
Western medicine, acupuncture in,
405–406, 409–410
wheeze
asthma, 96
668
COPD, 88 International Classification of
cystic fibrosis, 93, 107 Impairment, Disability
WHO see World Health Organization and Handicap (1980),
winging of scapula, 231, 324t 192
wobble board, 248, 290–291 wound
Wolff’s law, 497 lung surgery, complications,
women, 605–635 173t
cardiac rehabilitation, 149 open see open wound
pelvic anatomy (incl. pregnancy), wringing (massage), 483–484
605–608 wrist
physiology, 611 arthroplasty, 530f
pregnancy see pregnancy fractures in area of, 512
work (mechanical) writing
angular, 361 of assessment, 215
of breathing, 130–131, 134–135 methods of reflection, 78–79
linear, 360 wry neck, 225
work (occupation) see employment
workforce, high-quality, 42–43
X
World Anti-Doping Regulations
Association (WADA), 370, X-ray radiograph
372 chest
World Confederation (Congress) for asthma, 87–88
Physical Therapy (WCPT), 4 bronchial/lung cancer, 120
International Organization of bronchiectasis, 104
Physical Therapists in COPD, 90
Women’s Health cystic fibrosis, 107
subgroup, 1–2 pleurisy, 112
interprofessional education, 24–25 pneumonia, 111
World Health Organization (WHO) preoperative, 171
acupuncture and, 407–408 tuberculosis, 119
on cardiovascular disease, 147 previous, records of, 211
health defined by, 188 xanthene derivatives, COPD, 92
International Classification of
Functioning, Disability
Y
and Health see
International yellow flags, 389
Classification of low back pain, 224b
Functioning, Disability yin and yang, 405
and Health yoga in pregnancy, 617